J' Michael Hasenkam

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• How Computer aided Dosing would help with Patient
  Self Management ?

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MANAGEMENT CONCEPTS

• General Physician
• Cardiologist/Hematologist
• Hospital Outpatient Clinic
• Thrombosis Service
• Computer Dosaging
• Patient Self Management

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CONVENTIONAL MANAGEMENT

• Go to Lab
• Analysis of blood specimen
• Result to doctor
• Perscription of Warfarin dosage
• Decide next visit
• Information to patient Comply with schedule
• ENTIRE LIFE!!

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THE MODERN PATIENT

• Knowledgeable about own therapy
• Influence
• Avoid role as a patient
• Travel
• Manage studies/professional work

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SELF MANAGEMENT OF OAT

• Less dependence of health care system
• Better awareness of therapy
• Improved compliance
• Co-responsibility for therapy
• Better management of OAT

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CONCERNS

• Home coagulometer reliable?
• Patients capable to analyze blood specimens?
• Can patients handle dosage adjustments?
• Who is responsible for patient complications?

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Week no. Hospital INR CoaguChek
INR Anticipated Skills Interview Self
Control Lab Check
Weeks no Hospital INR CoaguChek
INR Anticipated Skills Interview Self
Control Lab Check
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COMPLICATION RATES

• BLEEDINGS
• Large Studies
• (AFASAK, BAATAF, SPINAF, SPAF (I,II,III)
• 1 3
• Everyday (Steffensen et al.)
• 6 (1 fatal)

• THROMBO-EMBOLISM
• Large Studies
• 2 4
• Everyday
• Reliable figures?

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CLINICAL END-POINTS
Serious Bleedings 14 (7 epistaxis 2
traumatic 5 GI/UG))
Expected (Steffensen) 33
Thrombo-embolic events 5 (2 DVT 1 ocular 2
fatal)
Expected (4) 22
370 patients 556 pt-years
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TIME IN THERAPEUTIC RANGE
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REASONS FOR SUPERIORITY OF SELF MANAGEMENT

• Frequent testing
• Patient training
• Dosage adjustment according to other factors than
  INR
• Patient selection (only compliant patients
  volonteer)
• Coagulometer ?

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Where does Computer Dosaging Fit in Here?
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CONTINUUM OF PATIENT CHARACTERISTICS

• Entirely self managing
• Self testing - dosaging with limits
• Self testing dosaging by health care provider
• Entirely dependent on health care provider

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CONTINUUM OF HEALTH CARE PROVIDERS

• Self managing patients superior to computer
• Specialists equal to/better than Computer
• GP/Young Doctors inferior to Computer
• Untrained Patients inferior to Doctor and Computer

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PLACE FOR COMPUTER DOSAGING

• Outpatient clinic
• General Physician
• Self testing patients
• Support in self managing by proxy
• Web based decision support
• Software at the patients home
• Web/e-mail report from patient to clinic

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PERSPECTIVES

• Computer dosaging central/near patient
• Improve quality of life
• Educate patients
• Improve compliance
• Reduce complications

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LETS INDIVIDUALIZE !
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• Self management
• Thrombosis Service
• Computerized Decision support
• Centralized
• Near Patient

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ISMAAInternational Self Management Association
for Anticoagulation

• Improve quality of OAT
• Reduce complications
• Promote self managed OAT
• Enhance patient involvement
• Improve Quality of Life for patients
• Cost-Effectiveness of care

http//www.ismaa-int.org
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MEANS

• Scientific Meetings
• Guidelines
• Courses for health care providers
• Interaction with other societies
• Interaction with patients (collaborators not
  traditional patients)
• Industrial collaborators

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Self managed
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Guidelines

• Patient Education
• Coagulometer Performance
• Demands for Training center
• Follow-up procedure
• Consultation for patients

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AGE
N 370
Years
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OAT DRUGS
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RELIABILITY
PRECISION Analytical CV 5 6 (short
term) 9 10 (long term) 2 3 (short
term) 7 9 (long term) ACCURACY Diff
lab. and Coaguchek CV 8 10 (varies over
time) Corresponds to diff. between laboratories
in DK

COAGUCHEK

LABORATORY
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INDICATIONS FOR OAT
Misc.
Mechanical Heart Valve
Coagulopathy
Atrial Fibrillation