Oral anticoagulant therapy and telemedicine

Abstract

We read the interesting paper by Testa et al.1 and the editorial comment by Pengo2 about the devolution of oral anticoagulant therapy (OAT) by using a telemedicine system that involves rest houses, peripheral hospitals and general practitioners. The architecture of the system, which improves quality of therapy and patient satisfaction, as those preliminary findings report, seems to be a valid future alternative in the monitoring of OAT. A few months ago, the Anticoagulation Clinic (AC) of Cagliari (Italy), which operates in the frame of the Italian Federation of Anticoagulation Clinics (FCSA), has started a similar project, by involving about 150 patients in selftesting and a control group matched for sex, age and diagnosis, followed by the AC and monitored by TAONET (EDP-Progetti, Bolzano, Italy). Patients were all on chronic OAT and criteria for enrollment in the study were the following: patients on OAT since at least 3 months; patients who cannot leave home because of serious physical illness, advanced age; patients who live far from the AC, lack of time due to hard work. The main outcomes of the study were the following: a) overdosage states, b) thrombotic and haemorrhagic events, c) time spent in the therapeutic range, and d) quality of life assessed by means of a questionnaire. After a training course, every patient received a portable coagulometer3 (Coagucheck S, Roche Diagnostics, Basel, Switzerland), which was submitted to a 3-monthly quality control by comparing the prothrombin time-INR measurement with that of the AC. We also asked the software house to create a personal and safe account to connect the patient to the referring AC through a web site. This procedure allows patients to interact with the AC where we use a system (TAONET), firstly designed by MM in 1999, to devolve OAT monitoring on territorial settings. We report here a brief description of the system: TAONET allows patient management in the territorial settings coordinated and assisted by the referring AC, the application to the involved territorial seats of the same quality standards as those of the AC, the extension of the procedure to all the remaining territory, with differentiated supports, according to the dedicated caregiver or to the patient himself. The system is developed on an Oracle standard procedure and is organised as a centralised netsupported program. The hardware is composed of a modular system, using a server and PC stations in the AC and workstations in the peripheral districts, and utilised by family doctors, nurses, pharmacies, and rest houses. Patients in self-testing can rely on a bidirectional connection with the AC; they can send their clinical data (e.g. pharmacological variations, intervening diseases, complications, etc.) and the INR value (obtained by portable monitor) by compiling a pre-set electronic datasheet and by receiving the schedule with the adjusted dose regimen at home in no more than 10 min. The questionnaire is relevant to dose assumption, pharmacological variations, possible haemorrhagic events, surgery, diet behaviour, and gives the patients the possibility of sending to doctors at the AC personal comments about the reported events. Every modification in therapy or in the clinical status will be simultaneously registered by the central data-base and will remain under control of the dedicated staff of the AC. The system allows a manual dose adjustment or an electronic proposal by the dose calculation algorithm of the program. Monitoring patients in self-testing could lead to an improvement in quality of life of the single patient even greater than that of patients monitored by the family doctors or by the nursing centres since it can be considered an “at home OAT monitoring”, under the direct control of the AC. Moreover, these patients have the possibility of interacting with the AC via this system, even when they are outside home or abroad, by simply finding an Internet point and using their personal connection to the web site. In conclusion, we think that in the near future this system could significantly improve the management of patients treated with coumarins. Even if this system will not be immediately available to all patients, a considerable proportion will save time and money, by simultaneously reducing the huge overcrowding in the AC. Coumarins could therefore be more resistant to the entry of new anticoagulants and to be still the drugs of choice in particular settings. Finally, a system like the TAONET could be helpful in the clinical monitoring of patients treated with new anticoagulants, which do not need a laboratory control as recently suggested4. A progressive lack in time of adherence to therapy may occur. Patients could periodically interact with the AC by answering a simple questionnaire on drug assumption, their general