Prothrombin self-testing:where the lab comes in
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Pathologists are not
directly involved with prothrombin time self-testing, but they are
aware of its value.
Two members of the CAP Coagulation Resource Committee, Tim Hayes,
MD, and Doug Triplett, MD, agree that self-monitoring of prothrombin
times can be a viable alternative for some patients. But, they say,
a physician must oversee the process.
"There are patients who would rather try to manage it themselves,
instead of going to a clinic or a lab for monitoring," says Dr.
Triplett, a professor of pathology at Indiana University School
of Medicine. "That’s a call for the physician who’s managing the
patient. He has to sit down and discuss the positives and negatives
of home monitoring."
Patients must be able to understand the process. "The No. 1 criteria
for making this successful is the commitment of the patient," Dr.
Triplett says. "Does the patient understand the consequences of
overdosing or underdosing?" The second important criteria is to
have a clinic or physician’s office with an infrastructure for helping
the patient manage anticoagulation therapy.
Says Dr. Hayes, "It has to be the right patient, the right physician,
and the right system" for home testing to work. By the right system,
he means a handheld device that is somewhat error-proof and ongoing
communication with the physician.
Drs. Hayes and Triplett say the hospital laboratory plays a peripheral
role in home monitoring, especially if a hospital-affiliated anticoagulation
clinic is managing the process. "The role for the lab is to assist
the physicians in understanding the risks of testing at home," says
Dr. Hayes, of the Maine Medical Center, Portland. "Ideally, the
lab would be perceived as a resource."
Dr. Hayes says it’s much easier for a central laboratory to coordinate
with a warfarin clinic than with 20 or 30 physician offices. The
ideal arrangement would be for the home testing to be performed
in connection with a centralized clinic that has a laboratory as
backup. "You don’t want it to get too fragmented," he says. "If
there’s a problem with a patient’s monitor, who do they go to? How
do you even know there’s a problem with a device used only once
a week?" Quality oversight must be maintained, he adds.
Dr. Triplett concurs. "This is something that can work," he says, particularly
because the devices on the market make it relatively simple. "Physicians and
patients who are involved with self-testing are very comfortable with it now."