Summary

County Durham and Darlington NHS Foundation Trust (CDDFT), Roche and Inhealthcare collaboratively created and piloted a self-testing service for patients who take warfarin, allowing them to be monitored outside the clinic. Patients used a self-testing device created by Roche to test their International Normalised Ratio (INR) levels and sent their results to the warfarin clinic through Inhealthcare’s automated platform. The entire project was overseen by staff at the CDDFT warfarin clinic, who contributed in the creation of its digital pathway. The project reduced the time patients spent attending the warfarin clinic and demonstrated significant lifestyle improvements. Meanwhile, there was an increase in the time patients were within their therapeutic range. CDDFT evaluations of service found it to be replicable and financially sustainable and, based on this, the Trust subsequently established a Health Call Monitoring service, in conjunction with Inhealthcare, as a permanent patient service. 

Challenge

Objectives

They were three-fold:

• To reduce the time patients spent in the clinic, thereby lessening work disruption, money spent travelling to the clinic and increasing the ability to travel while taking warfarin – all the while maintaining patients’ feeling that they were being monitored safely, and that the warfarin clinic staff were still accessible if they were needed. 

• To improve the service of the warfarin clinic, making the process of monitoring conditions simpler and easier for both patients and staff. 

• Improving patient outcomes, assessing what percentage of the time patients were within the therapeutic range (TTR) – i.e. taking the correct dosage – while on the trial, in comparison to the percentage of patients who were within TTR beforehand.

Solution

Inhealthcare, Roche and CDDFT collaborated to create a self-testing service, the Health Call INR Monitoring system. This allowed patients to test their own blood and adjust warfarin dosage based on feedback from clinicians who automatically received their patients’ test results. 200 patients participated in the pilot scheme, 100 of whom were hand-picked by CDDFT staff: Cohort 1), while the other 100 were broadly recruited from advertisements (Cohort 2). The home monitoring device (CoaguChek XS) used by patients to measure their INR - a measure of how quickly the blood clots - was designed and created by Roche, while Inhealthcare developed the N3-based healthcare platform (the digital integration system) which powered the automated process. Patients were trained to take a finger prick blood sample, put it onto a test strip then place the test strip into CoaguChek XS monitor, which provided the patient with a reading of their INR. The patient then received an automated phone call, prompting them to enter their INR reading on the key pad and the day’s warfarin dose. Inputted information was then sent to the warfarin clinic through the Inhealthcare portal and, using anticoagulation software, the patient’s warfarin dose and date of next INR test was determined. The Inhealthcare service then called the patient back with their warfarin dose and the date of their next INR test. The process was overseen by CDDFT staff, who were immediately alerted to adverse readings.

Results

Prior to the project, patients made 18 clinic visits – but during the project this decreased to a single visit. Patients reported that the self-testing service had lessened the impact on work and money lost from taking annual leave to visit the clinic. They also reported that they were able to test themsleves on holiday. All patients agreed or strongly agreed that the trial had been beneficial to their lifestyle and that they would recommend the telehealth service to other people.

Learnings

One of the unexpected benefits of self-testing was that it improved the clinic experience: clinician feedback showed the trial has improved the quality of time they spent with patients who did attend. The project was particularly successful for people who were working and therefore found it difficult to get into the clinic: they were attracted by the lifestyle flexibility that self-testing afforded them – and were no longer bound by hospital appointments. So self-testing is not the desired option for everyone, but benefits do come from providing patients with the option.

Evaluation

Patient outcomes improved during the trial, suggesting that patients’ dosage was better managed with the Health Call system that it was traditionally by clinic visits. In Cohort 1, average TTR rose from 60.4% six months before the study to 74.4% six months after; in Cohort 2, the comparable figures were 59% and 75%. All patients felt the telehealth service had helped them gain better control of their INR overall, and helped them feel more involved in their care. All staff agreed or strongly agreed self-testing had helped patients gain a greater understanding of their INR results, and that they would recommend the service to patients who met the criteria for self-testing. The INR Digital Health service can be cost neutral from the perspective of variable NHS costs per patient compared to the INR outpatient clinic when the savings from the reduction of strokes and other thromboembolic events for patient self-monitoring is taken into account. Variable INR monitoring costs per patient are lowest for the INR outpatient clinic at £152 per year compared to satellite clinics (£190) or home care (£333). Costs for INR Digital Health are estimated at £140.88 per patient per year for the cohort of 300 patients where the meters are already funded separately, while costs for fully funded INR Digital Health is estimated at £200 per patient per year.