Thromb Haemost 2022; 122(04): 492-505
DOI: 10.1055/a-1677-9608
Coagulation and Fibrinolysis

Clinical Outcomes of Different Warfarin Self-Care Strategies: A Systematic Review and Network Meta-Analysis

1   Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
Kansak Boonpattharatthiti
1   Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
2   Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chon Buri, Thailand
Treeluck Thammathuros
1   Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
Piyameth Dilokthornsakul
3   Department of Pharmacy Practice, Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
Itsarawan Sakunrag
1   Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
Beth Devine
4   The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle, Washington, United States
› Author Affiliations
Funding This study received financial support from Naresuan University's Faculty of Pharmaceutical Sciences Research Fund.


Aim To compare the effects of different strategies for warfarin self-care.

Methods PubMed, EMBASE, CENTRAL, CINAHL, ProQuest Dissertations & Theses, and OpenGrey were searched from inception to August 2021. Randomized controlled trials (RCTs) of warfarin self-care, either patient self-testing (PST) or patient self-management (PSM), were included. Self-care approaches were classified based on the TIP framework (theme, intensity, provider): (1) PST ≥1/week via e-Health (PST/High/e-Health); (2) PST ≥1/week by health care practitioner (PST/High/HCP); (3) PST <1/week via e-Health (PST/Low/e-Health); (4) PSM ≥1/week by e-Health (PSM/High/e-Health); (5) PSM ≥1/week by patient (PSM/High/Pt); (6) PSM <1/week by patient (PSM/Low/Pt); and (7) PSM with flexible frequency by patient (PSM/Flex/Pt). Mean differences (MDs) and risk ratios (RRs) with 95% confidence interval (CI) were estimated using frequentist network meta-analyses with a random-effects model. The certainty of evidence was evaluated using CINeMA (Confidence in Network Meta-Analysis).

Results Sixteen RCTs involving 5,895 participants were included. When compared with usual care, time in therapeutic range was higher in PSM/High/Pt and PST/High/e-Health with MD [95% CI] of 7.67% [0.26–15.08] and 5.65% [0.04–11.26], respectively. The certainty of evidence was rated as moderate for these findings. The risk of thromboembolic events was lower in the PSM/Flex/Pt group when compared with PST/High/e-Health (RR: 0.39 [0.20–0.77]) and usual care (RR: 0.38 [0.17–0.88]) with low and very low level of evidence, respectively. There was no significant difference in the proportion of international normalized ratio (INR) values in range, major bleeding, and all-cause mortality among different self-care features.

Conclusion Patient self-care (either PST or PSM) by measuring INR values at least once weekly is more effective in controlling the INR level.

Supplementary Material

Publication History

Received: 23 June 2021

Accepted: 20 October 2021

Accepted Manuscript online:
25 October 2021

Article published online:
20 January 2022

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
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