TY - JOUR
T1 - At-Home Versus In-Clinic INR Monitoring
T2 - A Cost–Utility Analysis from The Home INR Study (THINRS)
AU - Phibbs, Ciaran S.
AU - Love, Sean R.
AU - Jacobson, Alan K.
AU - Edson, Robert
AU - Su, Pon
AU - Uyeda, Lauren
AU - Matchar, David B.
AU - writing for the THINRS Executive Committee, for the THINRS Executive Committee
N1 - Publisher Copyright:
© 2016, Society of General Internal Medicine.
PY - 2016/9/1
Y1 - 2016/9/1
N2 - Background: Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. Objective: To perform a cost–utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. Patients/Interventions: In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. Results: PST and HQACM participants were similar with regard to gender, age, and CHADS2score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, −$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. Conclusion: Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.
AB - Background: Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. Objective: To perform a cost–utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. Patients/Interventions: In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. Results: PST and HQACM participants were similar with regard to gender, age, and CHADS2score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, −$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. Conclusion: Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.
KW - anticoagulants
KW - atrial fibrillation
KW - cost effectiveness
KW - heart valve
KW - randomized trials
UR - http://www.scopus.com/inward/record.url?scp=84970996558&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84970996558&partnerID=8YFLogxK
U2 - 10.1007/s11606-016-3700-8
DO - 10.1007/s11606-016-3700-8
M3 - Article
C2 - 27234663
SN - 0884-8734
VL - 31
SP - 1061
EP - 1067
JO - Journal of General Internal Medicine
JF - Journal of General Internal Medicine
IS - 9
ER -