Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment).
A Cochrane review[Abstract] 1 included 28 studies with a total of 8 950 subjects. Patients who self-test can either adjust their medication dose according to a pre-determined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Compared to standard therapy, self-monitoring or self-management of oral anticoagulation led to a significant 50% reduction in thromboembolism but no reduction in all-cause mortality. However, trials of self-management led to a significant reduction in all-cause mortality. In those groups that self-managed the effect for thromboembolic events was larger than in the groups that self-monitored (table T1) Self-monitoring or self-management did not reduce major haemorrhage (RR 0.95, 95% CI, 0.80 to 1.12; 20 studies, n=8018) or minor haemorrhage (RR 0.97, 95% CI 0.67 to 1.41; 13 studies, n=5 365).
| Outcome and intervention | RR (95% CI) | Assumed risk - standard care | Corresponding risk - intervention (95% CI) | Participants (studies) |
|---|---|---|---|---|
| Thromboembolic events | ||||
| Self-monitoring or self-management | RR 0.58 (0.45 to 0.74) | 35 per 1000 | 21 per 1000 (16 to 26) | 7 594(18 studies) |
| Self-monitoring | RR 0.69(0.49 to 0.97) | 35 per 1000 | 24 per 1000(17 to 34) | 4 097(7 studies) |
| Self-management | RR 0.47(0.31 to 0.70) | 36 per 1000 | 17 per 1000(12 to 25) | 3 497(11 studies) |
| All-cause mortality | ||||
| Self-monitoring or self-management | RR 0.85(0.71 to 1.01) | 64 per 1000 | 54 per 1000(45 to 64) | 6 358(11 studies) |
| Self-monitoring | RR 0.94(0.78 to 1.15) | 90 per 1000 | 85 per 1000(70 to 104) | 3 300(3 studies) |
| Self-management | RR 0.55(0.36 to 0.84) | 33 per 1000 | 18 per 1000(12 to 28) | 3 058(8 studies) |
Self-monitoring and self-management are not feasible for all patients, which requires the identification and education of suitable patients.
Primary/Secondary Keywords