One of the changes coming to medicine is the return of the delivery and management of health care in the patient’s home. Driving this trend are potential cost savings, greater patient involvement in and satisfaction with care and no worse quality, all facilitated by technology, including communication technology. The New England Journal of Medicine has an article on home testing of warfarin versus testing in a medical clinic. (NEJM Article) Warfarin is a very commonly used blood-thinner, with millions of patients on it at any one time. Management of warfarin therapy is centered around something called the international normalized ration (INR) and there are point of care devices to check this. The study followed about 3000 patients for two to almost five years.
The patients randomized to self-care did a weekly check of INR and those going to a clinic had monthly testing. Home care patients reported results via interactive voice response and web systems. The end points were time to occurrence of stroke, major bleeding episode or death. The two groups did not vary significantly in regard to these end points, indicating that neither method of managing warfarin therapy was superior to the other. The home care group did, however, spend more time with their INR in an appropriate range and had greater satisfaction with the care and reported a better quality of life. The great majority of patients in the self-care arm were able to be trained to do testing and were adherent with the testing schedule.
Some news accounts have portrayed this study as a failure, primarily because it did not find a clear superiority of home testing, as some earlier research had suggested, but that is the wrong perspective. The study is a strong confirmation of the notion that patients can be trained to handle relatively complex medical care and will have outcomes at least as good as those that occur when professionals are delivering the care. Increased patient satisfaction appears to result as well. Moving care to the least expensive setting is a trend that is unlikely to go away and research continues to show that self-care can be performed successfully for many chronic health problems.