Personalising care across a whole pathway leads to more precise treatment regimes, better outcomes and greater resource efficiency. In this session we will demonstrate how by applying technology to various stages of the anti-coagulation we can achieve greater health gain at lower costs.

1. Personalised anti-coagulation: an example of how
technology drives efficacy and efficiency.
Simon Jones
Dr Harsh Sheth

2. Content
• Personalised medicine
• Alignment of the right treatment with the right patient to achieve the greatest
clinical outcomes and cost effectiveness
• Using technology to test sensitivity prior to treatment
• The more we understand before embarking on course of treatment the more
effective it should be
• Optimised medication regimes
• Once on treatment regime – let’s optimise it

3. Personalised anti-coagulation pathway
• Two main treatments – Warfarin, NOAC
• Both NICE approved
• Both appropriate treatment options
• Huge cost differential
• Given health gain from each drug it’s important to understand cost v health
gain
• Inconsistent prescribing patterns
• Local variations on which treatment to use
• Some based on cost others on more clinically based protocols

4. The Warfarin Patient
A patient now
Mary, 58 with AF. GP prescribes warfarin, misses appointments, collapses, severe
internal bleeding, lucky to survive…
In the future
….. Mary is one of the 4-5% who metabolise warfarin slowly…. .Mary’s GP does a quick
pharmacogenetics test using special equipment in the surgery…… starts on lower, safer
dose of warfarin… suited to personal genetic makeup.
OR… test shows Mary is sensitive to Warfarin so GP prescribes NOAC.

5. Pirmohamed M et al, New England Journal of Medicine 2013
In a multi centre trial involving Newcastle, genotype guided dosing
resulted in participants reaching the therapeutic window earlier and
with fewer episodes of over dosing
A simple test of three variants responsible for
two thirds of the interpersonal variation

6. Routing of patients to warfarin/ NOAC based on
genotype
Reduced bleeding with endoxaban in sensitive and highly sensitive responders compared to
warfarin (low dose P=0.0036; high dose P=0.0066)
Mega et al. Lancet 2015
6mg,
24%
5mg,
7%
4mg,
31%
4mg,
4%
4mg,
1%
3mg,
0.5%
4mg,
8%
3mg,
6%
3mg,
1%
3mg,
13%
2mg,
3%
2mg,
0.1%
1mg,
0.2%
1mg,
0.1%
2mg,
1%
1mg,
0.3%
2mg,
0.2%
2mg,
2%

7. Patient self-tests INR
at home on agreed
date
Using either an automated phone
call or on-line submission, the
patient provides their INR reading,
current warfarin dose, and
questions around bleeding and
medication
Patient follows new
dosing regime and
notes date of next test
The service can integrate directly
with 4S-DAWN or INRstar. This means
that clinic staff can dose from within
their existing system, or from the
Inhealthcare portal if the clinic uses a
different decision support system
The service then informs the
patient of their warfarin dose
and the date of next INR test

8. Patient INR Self-Testing
• There are 1.2 million people in the UK that are on
warfarin, creating 17 million out-patient appointments
per year to have their blood tested (INR tests)
• This service allows patients on warfarin to self-test their
INR at home instead of attending out-patient clinic, and
then for them to receive their new warfarin dose at home
• When assessed, the self-testing patients had a higher
level of compliance than clinic-based patients, meaning
that the time
that their INR was in a safe range increased from 59% to
72%.
Evaluation data from 200 clinical patient pilot at NHS County Durham
and Darlington NHS Foundation Trust

9. North East Project
Stage 1
• Request genotyping on all “problem cases” and new cases of AF
• Consider switching “high risk” cases to NOAC
• Increase numbers of self testing – to secure increased TTR
Stage 2
Redesign anti-coagulation pathway so we can:
• Genotype all new referrals
• Accelerate induction of “wild type”
• Align appropriately those patients who would achieve better outcomes through self testing

10. Summary
• Introduction of 3 innovations to the clinical pathway- rapid genotyping,
self testing INR and cloud based warfarin dose adjustment
• Objective stratification of patients to warfarin or NOAC treatment
• Improved INR control, improved drug adherence, reduced risk of
bleeding events and reduced clinic visits
• Overall cost saving of ~£3 million in Newcastle area alone

11. • Please come and see us on stand 73
• Any questions?
• Follow Inhealthcare on Twitter @InHealthcareUK