Heartfelt with Dr Melissa Walton-ShirleyView all posts »
THINRS--- Study of HOME INR monitoring MISSES the POINT : the need for UNIVERSAL "point of care" INR monitoringNov 12, 2008 12:16 EST
First of all, I want to congratulate Drs. Matchar and Jacobson for a very important trial and one that will eventually help those of us who are proponents of home INR testing to drive the change so desperately needed in our country's very costly difficulties with warfarin monitoring. It's an almost insurmountable task to reign in a drug that is often prescribed and monitored in a rogue and disorganized fashion. Even though INR levels can produce catastrophic disability from stroke or can produce devastating morbidity and drive up mortality from bleeding, we have made no efforts at formally standarizing our monitoring methods in this country. 'And it could be SOOooooo simple.
Simply put: If one is going to prescribe warfarin, one needs to have point of care testing available either in the office or in the patient's home. PERIOD.
Even though I respect the efforts made in this study, THIS STUDY DOES NOT REPRESENT REAL WORLD EXPERIENCE WITH COUMADIN.
Let's test that hypothesis. How many physicians, non cardiologists or cardiologists have point of care testing available in their own office? We run a protime clinic in our office every Mon. Tues, Thurs. and Fri. from 8 am-10 am. No appointment necessary. But many physicians who prescribe coumadin do not.
For our clinic you just Bring your finger, we will stick it and we will tell you in 120 seconds what your protime is and in the same breathe, tell you whether to hold your dose, double it, halve it, etc. or just keep on doing what you are doing. "See ya next month" is very common way to say goodbye in our protime clinic unless a change has been made in the dose or dosing regimen.
Compare the above practice to the real world of INR testing for many patients.
Let's follow Ms. Jones on coumadin for a prosthetic valve in the mitral position with an EF of 32%. She travels 18 miles into town, to the lab with a protime slip. She leaves a blood sample at the free standing lab or at the lab in the hospital at 2 pm. The lab runs the blood and mails or faxes it to the doctor's office. The staff closes up and goes home at 5 pm. The result is still on the fax machine at 8 am when the office closes. It's Tuesday, the staff collects all the overnight faxes the next morning. With about 65 lab slips in hand, it's handed to the filing person. The filing person then tries to locate all those charts, some of which can't be located. Ms. Jones chart is one of them. She then puts Ms. Jones lab slip on Dr. Martin's desk, with no chart. 4 other staff persons pile more work on top of Dr. Martin's desk. Dr. Martin, about to go over his desk at the end of the day is called to the hospital. He does not return to his desk until Thursday because Wednesday is Dr. Martin's half day at the hospital, then has the afternoon off. Thursday, Dr.Martin has a very hectic day. Finally at 5 pm on Thursday, he sees Ms. Jones INR of 1.2. drawn on Monday. He panicks a little tries to call Ms.Jones, only to find that Ms. Jones is not home. Unknown to him, she has traveled to her sister's house in the next town to spend the weekend,. Ms. Jones thinks everything is great because she has been told "if you don't hear from us, everything is OK". Ms. Jones wakes up at her sister's home Saturday morning and can't speak and is taken to a local hospital where she is admitted for stroke. Monday, Dr. Martin's office staff reaches her daughter to tell her that her INR is subtherapeutic that was drawn a week ago. Her daughter is distraught, the patient is harmed,the physician is also devastated to hear of this turn of events.
This scenario is a horrible tragedy for the patient and a terrible outcome for the doctor who cares about their patients but is trapped by an inefficient system designed to increase morbidity and mortality in warfarin dependant patients. THis tragedy could be diverted multiple times daily in this country......with a common sense approach.
Transform the above scenario in this way: Ms. Jones travels 18 miles to Dr. Martin's office, gets her finger stuck and in 120 seconds learns she needs to go into the hospital for heparin therapy until her INR is therapeutic. Cost of three days of heparin vs. a lifetime of after- stroke care? NO COMPARISON. You can do the same thing for bleeding. What if her INR had been 4? One week later, she's had her IC or GI bleed entirely preventable by just instructing the patient to hold her coumadin and recheck.
Even better yet,thanks to THINRS we now know it's SAFE for her to get out of bed, start her morning decaf, sit at her kitchen table and stick her finger. "Wow, my protime is up today, better call the office". She gets her instruction and proceeds on in whatever is best for her and her anticoagualtion needs.
REIMBURSEMENT for MEDICARE AND MEDICAID should be tied to having point of care testing available in every single physician's office and clinic in this country.
It's a hard line, but coumadin is a hard pill to swallow.