Questions are often raised as to whether self-monitoring is as effective as close monitoring by a clinic. Connock and coworkers reviewed the evidence to determine the clinical effectiveness and cost-effectiveness of self-testing and self-management of oral anticoagulation treatment compared with clinic-based monitoring. A review of relevant data from selected studies was done. Results about complications and deaths were pooled in meta-analyses using risk difference as the outcome statistic. In the 16 randomized and eight nonrandomized trials selected, patient self-monitoring of oral anticoagulation therapy was found to be more effective than poor-quality usual care provided by family doctors, and as effective as good-quality specialized anticoagulation clinics in maintaining the quality of anticoagulation therapy. There was no significant risk difference of major bleeding events between patient self-monitoring and usual care controls and pooled analyses found that compared with primary care or anticoagulation control clinics, self-monitoring was statistically significantly associated with fewer thromboembolic events. However, the reduction in complication events and deaths was not consistently associated with improvement of clinics; in some trials this may be due to alternative explanations, including patient education and patient empowerment. Also, improved clinics and the reduction of major complications and deaths by patient self-monitoring were mainly observed in trials conducted outside the United Kingdom. Seven cost-effectiveness studies were identified; the study that provided the most relevant UK data found that patient self-management was more expensive than current routine care and concluded that using a cost-effectiveness threshold of 30,000 pounds per quality-adjusted life-year gained, patient self-management does not appear to be cost-effective. Projecting these costs over time, however, suggested that self-monitoring would be cost effective over a ten-year period.

VALUE OF STUDY TO READER: The authors concluded that for selected and successfully trained patients, self-monitoring is effective and safe for long-term oral anticoagulation therapy. In general, patient self-management was unlikely to be more cost-effective than the current specialized anticoagulation clinics in the UK; self-monitoring may enhance the quality of life for some patients who are frequently away from home, who are in employment or education, or those who find it difficult to travel to clinics. Further research is needed on the issue of self-monitoring versus clinic monitoring, particularly over a period of time. If these studies are conducted, self-management based on self-monitoring will likely emerge as the most effective procedure with lower costs that can be conducted with patients receiving anticoagulation therapy.

M Connock et al. Clinical effectiveness and cost-effectiveness of different models of managing long-term oral anticoagulation therapy: a systematic review and economic modelling. Health Technology Assessment, 2007;11:1-86.