Anticoagulation Clinic in National Heart Centre Singapore (NHCS) rolled out two initiatives to improve patient care and care experience for patients requiring long-term anticoagulant treatment.

Anticoagulants, also known as blood thinners, are medications prescribed for the prevention or treatment of blood clots by slowing down the formation of the blood clots. The most commonly prescribed anticoagulant is warfarin.

For patients who are on anticoagulants, it is crucial to regularly check and monitor their international normalised ratio (INR) – a test that measures the time it takes for blood to clot. NHCS Anticoagulation Clinic (ACC) provides various programmes to patients on warfarin therapy who require INR monitoring.

Caring remotely and effectively

Since 2016, NHCS ACC started a pilot telehealth service for selected patients who are on follow-up care. Comprising home INR monitoring and phone consultation, this telehealth service allows the care team to render care to patients in an effective and safe manner, while reduces the need for patients to make a physical visit the clinic at NHCS. This helps save patients and their caregivers’ time and money from travelling and waiting at the clinic.

Patients who have unstable INR and require frequent monitoring are encouraged to sign up for this telehealth service, which is run by a team of trained Advanced Practice Nurses and Pharmacists. Prior to enrolment, the care team will assess the patients’ suitability for the programme. Patients will be required to have their own portable ‘point-of-care’ (POC) INR test devices (for home-based use). They will be taught on how to perform INR self-test at home and send their results via a secured web application.

Upon receiving the INR results, the care team will call the patients the next working day to conduct a routine check on patients’ well-being such as symptoms, bleeding signs, lifestyle, diet and medications. Patients will also be advised on the appropriate adjusted warfarin dosage, if necessary, and the next self-test schedule and appointment. The entire phone consultation will be documented and assessed clinically.

NHCS ACC had successfully enrolled more than 100 patients for the Home INR monitoring service since its official launch in July 2020.

Developing predictive model for self-titration

Recognising the need to further enhance INR monitoring, the ACC team began to research and study past prescribing data, so as to develop a predictive model for warfarin titration and validate an algorithm for self-titration. Till date, the team has identified more than 7,000 patients who had undergone clinic-based warfarin titration, and with the analysis of over 253,000 INR values and 285,000 warfarin prescriptions, the team hopes to be able to establish a predictive model and algorithm in three years, which could potentially help patients to perform self-titration of the warfarin dosages more effectively.

Empowering self-management INR care

While these initiatives were recently rolled out, brainstorming and discussions for ideas began as early as five years ago when the CC team saw the need to provide an alternative to the standard face-to-face treatment at the clinic, “We hope that such initiatives will empower patients to better manage their own health at home and bring about improved health outcomes. We are happy to see many patients who could self-test more frequently at home, and are taking a faster time to reach therapeutic range,” shared Asst Prof Fam Jiang Ming, Senior Consultant from the Department of Cardiology at NHCS, who is also currently leading the ACC team.

The team plans to transit selected patients from a traditional clinic-based model to a home-based patient-led (self-management) model, which can lead to both cost and time savings for both patients and the healthcare institution.

While the ACC service is in the process of evolving into a full-fledged clinical service, the team foresees a demand for such telemedicine services in the near future. Visualising on advancement in clinical care, the team envisaged that patients would be transited from a semi-autonomous care model, in which they perform INR self-testing followed by warfarin dose titration guided by the healthcare professionals remotely, to a fully-autonomous care model where patients are able to self-test and self-titrate, with the help of a software-based algorithm that can recommend warfarin dosages and intervals. In this model, healthcare professionals can monitor the progress of these patients remotely at predetermined intervals and actively manage their conditions only when necessary.

Patients who are interested in Home INR Monitoring may speak to their care team.