POC testing by patients to monitor their laboratory values at home saves valuable time both for health care professionals and for patients themselves. Self-monitoring can even improve treatment results.
The POC test device is slightly larger than the average smartphone. 73-year-old Marja-Liisa Heikkilä from Helsinki inserts the test slip in the POC device and squeezes a drop of blood from her fingertip onto the slip. The device returns the result almost instantly. The value is 1.8, which is only slightly below the normal value.
Monitoring is quick and easy, Marja-Liisa smiles.
Marja-Liisa Heikkilä is one of 50 warfarin users participating in the self-care test for Helsinki University Hospital Coagulation Disorder Unit and HUSLAB. The pilot project has ended, but most participants continue self-testing in monitoring their INR values. Approximately 100 Helsinki University Hospital patients have INR self-test devices.
Previously, Marja-Liisa Heikkilä needed to visit a laboratory every three weeks to have her INR test taken. Now she can take the INR blood test at home or, should the need arise, even in a restroom at the international airport of the bustling megapolis of Seoul, like she did when she recently visited South Korea.
Home care is an excellent option for those who want to take care of themselves and who do not wish to sit and wait at laboratories. However, this requires some dexterity, Marja-Liisa ponders.
Marja-Liisa Heikkilä has explicit instructions on what to do, if her test results exceed the specified INR range. If the deviation is minor, she may adjust the dosage herself. Major adjustments need to be discussed with a nurse from the Coagulation Disorder Unit.
Marja-Liisa Heikkilä is already familiar with making adjustments to her dosage. Previously, she received her INR test results from the hospital laboratory as an SMS to her phone. Now she takes the tests herself at home.
Especially in the winter, it is convenient that you do not need to drive to the laboratory in snow and sleet, Marja-Liisa says smiling.
Good care prevents strokes
Tuukka Helin, Specializing Physician in Hematology and Clinical Chemistry at HUSLAB and Lotta Joutsi-Korhonen, Chief Medical Officer for the unit, as well as clinical physicians at the Coagulation Disorder Unit were responsible for the warfarin self-care pilot project. The results of the pilot project were so good that there are plans to extend the activity to all of the municipalities in the region where Helsinki University Hospital operates.
Patients who are trained in self-care feel that they receive good care: they are able to take care of themselves and they have a named contact nurse at the unit who is responsible for giving guidance to self-care patients, Helin says.
Results are impressive: 80% of home care patients have good TTR (time in therapeutic range) values, that is, higher than 70%, which means that the blood INR values are within the treatment target range more than 70% of the time.
The objective of self-care is to improve patients’ treatment balance which in turn can decrease the likelihood of serious complications, such as strokes, Helin says.
Deviations in diet, use of alcohol or stomach upsets can affect blood INR values.. Patients on warfarin are usually the best experts in what is causing any deviation.
Tuukka Helin estimates that more than half of patients on warfarin could benefit from home care. However, substance abuse and memory disorders as well as motoric issues can limit the possibilities of successful self-care.
Initially, home care is more costly because patients need equipment and training to use the devices. Test slips are also slightly more expensive than ordinary INR blood tests at laboratories.
After the initial investments, self-care saves health care resources: patients are able to solve most cases independently, which means less calls to health care centers and polyclinics.
Helin says that self-care of warfarin INR blood values is part of a larger trend where patients are increasingly assuming responsibility for their treatment.
Patients are the best experts when it comes to their health through their own experiences. Doctors and nurses will become consultants who deal with more challenging situations.
Quick tests to diagnose bowel diseases
Home tests would also be useful for other chronic diseases where treatment balance is regularly monitored with laboratory tests.
Examples include inflammatory bowel diseases, such as Crohn’s disease and colitis ulcerosa, where relapses are difficult to anticipate.
If patients could test disease markers at home, unnecessary routine checks could possibly be avoided and patients could contact us sooner in case of a relapse, says Anna-Maija Puolanne, Specialist in Internal Medicine and Gastroenterology.
Currently, patients often endure their symptoms at home for an unnecessarily long time, a rapid test could easily be used to check whether the symptoms are due to a relapse or other stomach issues. Tests could also be used to screen out any suspicion of bowel disease.
Research shows that when patients are more knowledgeable of their disease and take more responsibility for it, their treatment is more effective as well. Patients are motivated to take their medication and know when to contact health care professionals if more intensive treatment is needed, Puolanne says.
Quick tests for bowel diseases to measure calprotectin and lactoferrin levels at home have been tested by Helsinki University Hospital. So far, the tests are easy to use but somewhat inaccurate.
There are more accurate tests where the result is an exact numeric value and the results will be submitted through a mobile phone app instead of a colour code. Puolanne believes that tests will be used routinely within the next few years.
Bowel diseases often appear at an early age and thus require long-term monitoring and medication. It would be a lot easier for the patient, if he or she did not need to call the polyclinic and drive to the clinic sometimes over long distances, but could take the tests independently at home, Puolanne says.
Laboratories check that instruments work
Although patients carry out laboratory monitoring, laboratories are responsible for the correct operation of instruments and for correct, reliable results.
In home care warfarin treatment, approximately every tenth test will be taken at a laboratory to compare the results from the home care device and a laboratory test. In addition, accuracy of the tests will be assured through control tests by the manufacturer of the home care devices and Labquality control samples.
According to Tiina Mäki, Chief Medical Officer for Preanalytics at HUSLAB, the objective of the laboratory is to ensure that patients have reliable POC devices the accuracy of which is monitored regularly and that patients operate the devices correctly.
Experts are needed to plan how patients will be taught to interpret their results. Clinics have a key role here, but laboratories can play a supporting role, Tiina Mäki says.
Tuija Männistö, Specializing Physician at NordLab in Oulu, emphasizes that POC tests taken at home should be as reliable as laboratory tests.
POC tests are not yet used in the Oulu region, but Männistö believes that they will soon be introduced.
Devices are constantly being developed and there are already POC devices that can be remotely monitored from the laboratory. In the future, we may be able to provide private individuals with these kinds of services, she envisions.
On the other hand, in the future there will still be a large number of patients, such as patients with memory disorders, who will not be able to use new technology. In addition, not all laboratory tests can be taken or interpreted at home reliably. Traditional laboratory monitoring by health care professionals will continue to be needed in the future as well.
Patients monitoring their warfarin treatment at home are still recording their INR results manually on paper. In the future, the data should be saved directly into the national patient information archive.
The treatment unit should be able to access the data
In order to be able to use POC home tests fully, health care professionals should be able to access the data conveniently.
Patients monitoring their warfarin treatment at home are still recording their INR results manually on paper. Test results are also saved on the device’s memory.
Our wish for the future is that patients can enter their results directly in the national patient information archive, so that the data could be immediately accessed everywhere, says Tuukka Helin, Specializing Physician at HUSLAB.
Tuija Männistö, Specializing Physician at NordLab also considers it important that data from self-tests carried out by patients would be made available for the treatment unit in real time.
At the moment, for example, blood glucose is mainly monitored with instruments that are not connected to the web. In the future, home care devices are also likely to be online and test results can be submitted to the treatment unit automatically, she predicts.
According to Männistö, patients’ home care test results should not necessarily be saved in the laboratory information system, if the devices are not controlled by the laboratory. However, it would be useful to save the results in the patient information system so that the relevant doctors and nurses can use the results for treating patients.
This requires resources to monitor the data. It is not sufficient for hospitals to have access to the data, if no-one has the time to monitor, interpret and react to the information, Männistö points out.
This article was first published in Finnish in Mylab Nyt magazine issue 2/2017.