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Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation
  1. Pawana Sharma1,
  2. Graham Scotland1,2,
  3. Moira Cruickshank1,
  4. Emma Tassie2,
  5. Cynthia Fraser1,
  6. Christopher Burton3,
  7. Bernard Croal4,
  8. Craig R Ramsay1,
  9. Miriam Brazzelli1
  1. 1Health Services Research Unit, University of Aberdeen, Aberdeen, UK
  2. 2Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
  3. 3Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
  4. 4Department of Clinical Biochemistry, University of Aberdeen, Aberdeen, UK
  1. Correspondence to Dr Miriam Brazzelli; m.brazzelli{at}abdn.ac.uk

Abstract

Objectives To investigate the clinical and cost-effectiveness of self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy compared with standard clinic care.

Design Systematic review of current evidence and economic modelling.

Data sources Major electronic databases were searched up to May 2013. The economic model parameters were derived from the clinical effectiveness review, routine sources of cost data and advice from clinical experts.

Study eligibility criteria Randomised controlled trials (RCTs) comparing self-monitoring versus standard clinical care in people with different clinical conditions. Self-monitoring included both self-management (patients conducted the tests and adjusted their treatment according to an algorithm) and self-testing (patients conducted the tests, but received treatment recommendations from a clinician). Various point-of-care coagulometers were considered.

Results 26 RCTs (8763 participants) were included. Both self-management and self-testing were as safe as standard care in terms of major bleeding events (RR 1.08, 95% CI 0.81 to 1.45, p=0.690, and RR 0.99, 95% CI 0.80 to 1.23, p=0.92, respectively). Self-management was associated with fewer thromboembolic events (RR 0.51, 95% CI 0.37 to 0.69, p≤0.001) and with a borderline significant reduction in all-cause mortality (RR 0.68, 95% CI 0.46 to 1.01, p=0.06) than standard care. Self-testing resulted in a modest increase in time in therapeutic range compared with standard care (weighted mean difference, WMD 4.4%, 95% CI 1.71 to 7.18, p=0.02). Total health and social care costs over 10 years were £7324 with standard care and £7326 with self-monitoring (estimated quality adjusted life year, QALY gain was 0.028). Self-monitoring was found to have ∼80% probability of being cost-effective compared with standard care applying a ceiling willingness-to-pay threshold of £20 000 per QALY gained. Within the base case model, applying the pooled relative effect of thromboembolic events, self-management alone was highly cost-effective while self-testing was not.

Conclusions Self-monitoring appears to be a safe and cost-effective option.

Trial registration number PROSPERO CRD42013004944.

  • CARDIOLOGY
  • HEALTH ECONOMICS

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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