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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Healthy Heart Healthy Heart
 

Home Monitoring Of Blood Thinners Comes Of Age


July 09, 2013

By Thomas H. Lee M.D.

Harvard Medical School

There are a lot of annoying things about living with the need to take the anticoagulant warfarin (Coumadin). This "blood thinner" is used to prevent strokes and other complications from blood clots for people with problems like atrial fibrillation, pulmonary embolism, and deep-vein thrombosis. The benefits can be life saving, but the problems include easy bruising, cuts while shaving that take forever to stop bleeding, and trips to the doctor every two to four weeks to get blood tests to be sure you are in a safe but effective range.

For warfarin users there's not much hope of relief for most of these issues, but that last annoyance — the frequent trips to the doctor — may be about to go away. And that is because insurance companies are starting to pay for home monitoring devices for patients who need to be on warfarin for long periods, and who are willing to get training on how to use the devices. Medicare and some commercial insurance companies cover home monitoring for patients under selected circumstances.

The instruments are small, light and portable, and can give an accurate INR result in a few minutes from a drop of blood from a fingerstick. (INR stands for International Normalized Ratio, and is the key test result in determining whether you have enough or too much blood-thinning activity. Too much blood thinning increases your risk of a bleeding complication; not enough means inadequate protection against blood clots.) The devices sometimes underestimate high INR levels, and overestimate low INR levels, but they are pretty good at letting you know whether you are "in range" or need adjustment.

The technology actually has been around for several years, and is used in many doctors' offices. But the cost of the devices (about $2,000) has been the show-stopper for most individuals who wondered why they need to drive to doctor's office, pay for parking, wait in the waiting room, and then drive back to home or work — just for a blood test that they could do at home.

Until recently, hardly any insurance companies would pay for these devices, but that trend seems to be reversing as many insurance companies will now cover them for patients who they are convinced will use them correctly. The reasons for this change of heart: People who use the home monitors appear to have better control of their blood thinning because they can monitor their INRs more frequently, and thus are less likely to have complications from too much or too little anticoagulation. In short, if you can master the use of one of these devices at home, you are probably safer than you would be otherwise. One study even showed a 52% reduction in risk of bleeding problems in people using a home anticoagulation monitor.

There are additional benefits that fall in the "gravy" category. The people who use these devices tend to be happier and more confident that they are in control of their medical problems. In addition, they save the insurance company the costs of office visits and office blood tests. Best of all, the use of the home monitor gives them back several hours per month to live their lives.

When using a home anticoagulation monitor, some patients call their physicians' offices with the results, and get guidance on regulation of medications. Others use a flow sheet with instructions on what to do when results are in various ranges (for example, "Increase dose by 2 milligrams if INR is X.") The patient clearly has a much greater responsibility for his or her own care, but the dividends are considerable.

Home monitoring is not for everyone. You have to need anticoagulation on a long-term basis, and you have to take an educational program to be sure you can use the device safely. The supplies to do the test are not cheap, and insurers tend to limit you to one test per week.

But the decision of Medicare and many commercial insurers to cover these devices is an enlightened step in the right direction that will allow many people to spend more time with their families or at work — and less time looking for parking spaces or reading old copies of magazines in their physicians' offices.

Thomas H. Lee, M.D. is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. He is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is the chairman of the Cardiovascular Measurement Assessment Panel of the National Committee for Quality Assurance.

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