INR self-testing case study
By Inhealthcare
Case Studies 4 March 2016

County Durham and Darlington Foundation Trust lead the way with INR self-testing

Inhealthcare has collaborated with one of the largest integrated acute and community service providers in England to deliver a home monitoring service for the 2,500 warfarin patients in the region.

The new automated service at County Durham and Darlington NHS Foundation Trust (CDDFT), has transformed how patients on long-term anticoagulation medication warfarin are monitored. The service enables patients to self-test at home and receive their adjusted warfarin dose via 4S DAWN’s anticoagulation dosing software. Previously patients on warfarin needed to attend clinic every few weeks for a simple blood test to check how quickly their blood clots, which is measured using the international normalised ratio (INR).

The objectives

With warfarin clinics at maximum capacity, the trust needed to look at ways of delivering more efficient anticoagulation services. The main objectives of the project included:

To cut costs by reducing the time patients spent in the clinic  To find new ways to tackle skill shortages by better monitoring, triaging and reducing unnecessary or nonattendance at clinical appointments. A key aim was to improve the use, focus and skill mix of existing staff without compromising the quality of care delivered.
To begin to develop self-management as a way to meet the NHS’ Five Year Forward View vision as well as to alleviate some of the pressures on the current service. This would increase capacity and efficiency, and also improve the warfarin clinic service for those complex patients requiring quality clinician time.
To bring convenience to patients and reduce disruption to their lives.

The service

With the new service, the patient takes a finger prick blood sample and inserts it into the Roche INR selftesting device (CoaguChek®). The patient sends their new reading securely to the local clinic via an automatic phone call and Inhealthcare’s national digital health platform integrates this new data into 4S DAWN which feeds into the patient record. The new warfarin dosage is calculated in 4S DAWN and is then automatically relayed back to the patient. Previously, the anticoagulation team calculated the patient’s dose, and input the data manually into the system. With this new added automation from 4S DAWN, the service is enabling first class proactive care.

The service enables patients the freedom to live a normal life, enabling them to go on holiday, and still send in their readings remotely. Patients will no longer have to take regular time off work, pay for travel or clinic car parks.
The simple to use software means that patients and carers of all technical abilities can benefit – as long as they have a landline, mobile or access to the internet

Results

(Data taken from a cohort of 200 patients)

  • Time in Therapeutic Range (TTR) increased by an average of 20% for 70% of those on the service.
    Clinicians felt that they were able to spend more quality time with the most complex patients requiring their care.
    The time required to dose patients fell from an average of 5 minutes to 3 minutes with the introduction of selftesting. With 4S DAWN’s added integration 3 minutes has now reduced to just 30 seconds. Ian Dove said: “With this 4S DAWN update our INR service delivers dosing information to our users at even greater speed. It reduces the burden on our staff to input data giving them more time to treat. The ease with which people on warfarin can test remotely and securely update their records showcases the role digital solutions can play in the future of healthcare across the UK.”
    From March 2013 – to March 2016, the service has saved the trust over 22,000 appointments.
  • High patient satisfaction feedback with 100% of those on the service saying they would recommend the service to others. CDDFT currently monitors approximately 400 patients remotely. “Sustainability has been strong with 90% of patients who joined the programme three years ago still part of it.” The reduction in appointments has lessened the impact on patients’ lives. Patients reported enjoying the day-to-day flexibility, and also being able to self-test on holiday,” says Ian.

Patient feedback

“If there’s a reason you can’t commit to the clinic or you’re working, this service will really help you out. I would never go back to relying on the clinic staff; I’d like to keep up this method of monitoring for as long as I can, because it’s better for everyone involved. Due to more people using the service and being able to self-test at home, the clinics and hospital car parks aren’t as busy so more of the clinician’s time can be spent with those complex patients who need it. I can’t fault the service; measuring my INR isn’t even an inconvenience anymore.”

Jeannie Hardy, telehealth programme manager at CDDFT, said: “We’ve had a number of our patients tell us that when they come to clinic they have to take the time as holiday. That of course isn’t good from a health point of view, that people aren’t getting their holidays and their time off.”

Sister Tracy Murphy a nurse at CDDFT, said: “The new system is optional although enthusiasm for it is very high among patients, primarily because it is so much more convenient for them. In addition, the training they receive gives patients a greater understanding of what can affect their INR, meaning they are finding it easier to remain within their ideal therapeutic range. A major benefit of this stability is a reduced risk of stroke.”

Results (Data taken from a cohort of 200 patients)
Time in Therapeutic Range (TTR) increased by an average of 20% for 70% of those on the service
Clinicians felt that they were able to spend more quality time with the most complex patients requiring their care
The time required to dose patients fell from an average of 5 minutes to 3 minutes with the introduction of self testing
With 4S DAWN’s added integration 3 minutes has now reduced to just 30 second
From March 2013 – to March 2016, the service has saved the trust over 22,000 appointments
High patient satisfaction feedback with 100% of those on the service saying they would recommend the service to others

The service has been a great success. We clinically led the development of a pathway for patients on warfarin treatment. It operates using a digital interface opposed to regular attendance at the warfarin clinic. Using digital health, patients are able to selftest their International Normalised Ratio, a key measure for warfarin users, using a remote monitoring device at a time and in a place to suit their individual circumstances and lifestyle. The system then allows a nurse to identify the required warfarin dose and send the new dose information back to the patient remotely

Ian Dove, business development manager at CDDFT
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