Gebruik van point-of care systemen bij patiënten met orale ... - KCE

KCE Reports 117 POC Anticoagulation 119
PST 15 24%** -€ 355.58 (-1459.55 to 204.75) 77.58%
26 24%** -€ 202.20 (-1306.17 to 358.13) 60.00%
52 24%** € 160.32 (-943.65 to 720.65) 28.88%
PSM 15 24%** -€ 429.34 (-1359.28 to 72.39) 91.74%
26 24%** -€ 367.23 (-1297.17 to 134.49) 85.06%
52 24%** -€ 220.44 (-1150.38 to 281.28) 67.24%
* Distribution = gamma(1.46;8.22;shift: 6.01). In the IMA/AIM data, the mean number of test was
17.6 and the median number of tests was 15.3; **24% of GP visits in usual care are maintained;
POC = Point of care; CI = credibility interval; GP = general practitioner; AC = Anticoagulation
clinic; PST = patient self-testing; PSM = patient self-management
8.5 GLOBAL CONCLUSION
Compared with laboratory INR testing, the testing of INR with point-of-care devices is
a good option for patients with long term anticoagulation with vitamine K antagonists.
Globally, POC testings increase patient’ satisfaction, lead to less thrombo-embolic
events and less all cause mortality but have no impact on the number of major bleeding
events.
Four potential organisation models are compared: two at patient level (PSM and PST)
and two at health professional level (POC by GP and POC in AC). PSM and PST
strategies need patient selection and training. In specific situations (such as child), PSM
or PST may be done by a close relative. External quality control is needed for POC
devices in each strategy.
• Patient self monitoring (PSM) is the first choice organisation at the patient
level with respect to clinical outcomes (less thrombo-embolic events and less
all causes mortality), and also at the payer level, because it is the dominant
strategy with the highest cost-savings.
• Compared with PSM, patient self-testing (PST) is the second choice at patient
level. PST improves thrombo-embolic events but not all causes mortality. For
the payer perspective the cost-savings are also lower and depend of the
number of INR tests and essentially of the number of GP visits maintained.
• Considering the use of POC by GP, there is not evidence that it improves (or
damages) the clinical outcomes of patients compared with usual care. From
the payer perspective, such strategy is cost saving compared with the same
number of laboratory INR testing. The increase of the number of POC tests
goes however always with an increase of the number of GP contacts and this
strategy is not yet cost-saving in a scenario of 26 tests/ patient/ year.
• Considering the use of POC devices by health professionals in anticoagulation
clinics, there is also not evidence that it improves (or damages) the clinical
outcomes of patients compared with usual care. In this strategy, the
incremental costs depends on several parameters: the number of opening
hours of the AC, the number of patients followed, the number of INR tests
per patient and per year, and especially the number of remaining GP
consultations or visits.
In conclusion, for patients who have the willingness and the ability to do it, PSM is the
best strategy. Patients scheduled to long term oral anticoagulation (or close relative of
such patients) should be encouraged and trained for PSM. For others patients who need
help for testing and/or management, several POC strategies (PST, POC at GP, and POC
at AC) were available, near usual care with laboratory INR testing, with advantages and
limits described in this report.