Pharmacist-managed Anticoagulation Research Articles

Quality of anticoagulation control among patients receiving vitamin K antagonist in pharmacist-managed anticoagulation medication therapy adherence clinic

Quality of anticoagulation control among patients receiving vitamin K antagonist in pharmacist-managed anticoagulation medication therapy adherence clinic

Successful Anticoagulation With Warfarin After Switching From Rifampin to Rifabutin.

A case of a patient receiving warfarin for pulmonary embolism (PE) concomitantly with rifampin for treatment of active pulmonary tuberculosis (PTB) is presented. A successful clinical intervention whereby the patient achieved therapeutic anticoagulation after switching to an alternative rifamycin antibacterial, rifabutin, is described. The drug-drug interaction between warfarin and rifampin is well known and documented. However, to our knowledge, no case reports of the interaction between warfarin and rifabutin have been published, and literature describing this interaction is lacking. We describe the case of a 27-year-old African American female referred to a pharmacist-managed anticoagulation clinic for treatment of PE with warfarin. The patient was also being treated for active tuberculosis with rifampin, isoniazid, pyrazinamide, and ethambutol. Warfarin was initiated and over the course of 1 month was continuously increased to a total weekly dose (TWD) of 140 mg without ever achieving the target international normalized ratio (INR) of 2 to 3. In an attempt to reach the target INR, rifampin was switched to rifabutin to minimize the drug-drug interaction with warfarin. Six days after this switch, the target INR was achieved with a lower warfarin TWD of 115 mg. Rifabutin interacts with warfarin to a lesser degree than rifampin and may be considered as an alternative in patients taking warfarin who require treatment with a rifamycin. For patients in whom therapeutic anticoagulation with warfarin has been difficult, the use of rifabutin may be considered in place of rifampin when the concomitant use of a rifamycin is required.

Real-World Comparison of Direct Oral Anticoagulants to Warfarin Among Patients with Atrial Fibrillation/Flutter Managed By an Anticoagulation Service

Introduction: The use of warfarin to prevent ischemic stroke in patients with atrial fibrillation/flutter (AF) requires routine international normalized ratio monitoring and frequent dose adjustments to optimize time in therapeutic range (TTR). While TTR are generally low in usual care, anticoagulation services are associated with improved TTR and clinical outcomes. The direct oral anticoagulants (DOAC) are preferred to warfarin for AF as randomized controlled trial (RCT) data have shown they are as effective in preventing stroke with a lower risk of bleeding, particularly intracranial hemorrhage, compared to warfarin. However, the mean TTR for warfarin-treated patients enrolled in these RCT were relatively modest (55-65%); thus, it is unclear if clinical outcomes would differ if patients in the RCT control groups had been managed by an anticoagulation service. The purpose of this study was to evaluate the real-world effectiveness and safety of DOAC compared to warfarin among patients with AF followed by an anticoagulation service. Methods: This was a retrospective, longitudinal cohort study conducted at Kaiser Permanente Colorado, an integrated healthcare delivery system with a pharmacist-managed anticoagulation service. Adult patients diagnosed with AF, newly initiated on a DOAC or warfarin, and enrolled in the service between 11/01/2015 and 12/31/2018 were followed until anticoagulant switch/discontinuation, a study outcome, membership termination, or 01/05/2019, whichever came first. The index date was the date of service enrollment. TTR and percent of days covered (PDC, a measure of medication adherence) were calculated for the warfarin and DOAC patients, respectively. The primary outcome was a composite of all-cause mortality, clinically-relevant bleeding, ischemic stroke, or systemic embolism. Secondary outcomes included the individual components of the primary outcome as well as follow-up healthcare utilization. Multivariate Cox proportional hazards (reported as adjusted hazard ratio [aHR] with 95% confidence interval [CI]) and negative binomial (reported as adjusted incidence rate ratio [aIRR] with 95% CI) regression analyses were performed to assess differences between groups. All aspects of this study were reviewed and approved by the KPCO Institutional Review Board before data collection. Results: There were 2928 patients included with 1537 and 1391 warfarin and DOAC patients, respectively. The cohort was primarily older, male, and white with moderate burden of chronic disease and baseline healthcare utilization. Warfarin patients had a mean TTR of 72% and were more likely to be female and Medicaid beneficiaries and have had dementia, depression, and pulmonary disease comorbidities (all p<0.05). DOAC patients had a mean PDC of 83% and were more likely to have had a baseline hospitalization (p<0.05). With adjustment for age, sex, Charlson comorbidity index, race, Medicaid status, baseline healthcare utilization, dementia, depression and pulmonary disease comorbidities, patients on a DOAC had an associated lower risk of the primary composite outcome (aHR 0.75, 95% CI 0.62 - 0.91), any clinically-relevant bleeding (aHR 0.68, 95% CI 0.51 - 0.92), gastrointestinal bleeding (aHR 0.62, 95% CI 0.46 - 0.54), systemic embolism (aHR 0.59, 95% CI 0.36 - 0.95), and follow-up hospitalization (aIRR 0.76, 95% CI 0.65 - 0.89) (Table). DOAC patients had equivalent risks of ischemic stroke, all-cause mortality, intracerebral bleeding, and follow-up emergency department visits (all p>0.05). Conclusions: This retrospective analysis of a large sample of real-world patients with AF managed by an anticoagulation service identified that DOAC use was associated with improved safety compared to warfarin. Despite high-quality warfarin management, use of DOAC was associated with lower risks of clinically-relevant bleeding, systemic embolism, and hospitalization compared to patients receiving warfarin for AF which reinforce the application of RCT findings to health systems with available anticoagulation management services. Future real-world studies should be conducted to confirm our findings with multiple healthcare delivery systems, a larger sample size, and assessments of the individual DOAC versus warfarin to provide further evidence of the effectiveness and safety of DOAC. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Drug-related problem characterization and the solved status associated factor analysis in a pharmacist-managed anticoagulation clinic.

Drug-related problems (DRPs) in a pharmacist-managed anticoagulation clinic (AC) have not been extensively studied. We aimed to characterize the DRPs in a pharmacist-managed AC, identify the factors associated with the solved status of DRPs, and analyze the secondary outcomes, including the safety and efficacy of AC service. The patients receiving services at a pharmacist-managed AC in a medical center for the first time from March 2019 to August 2020 were reviewed retrospectively. The DRPs were retrieved from a self-developed Intelligent AC Service System and classified according to the Pharmaceutical Care Network Europe Foundation v9.0 classification system. Logistic regression models were performed to identify the potential factors associated with the solved status of DRPs. A total of 78 direct oral anticoagulant (DOAC) and 34 warfarin users were included. The major types of DRPs identified at the initial service were adverse drug events (ADEs) (68.4%) and untreated symptoms or indications (14.8%) in the DOAC group, and ADEs (51.6%) and suboptimal effect of drug treatment (38.7%) in the warfarin group. The rates of totally solved DRPs were 56.8% and 51.6% in the DOAC and warfarin groups, respectively. According to the multivariable analysis, receiving AC services 3 times or more in 180 days (OR 3.11, 95% CI 1.30–7.44) was associated with the totally solved status of DRPs in the DOAC group, but no relevant factor was identified in the warfarin group. The secondary outcomes showed that DOAC users demonstrated fewer thromboembolism events, major bleeding, and bleeding-related hospitalizations after AC services, whereas the warfarin users increased percentage time in therapeutic range (TTR% 55.0% vs. 74.6%, P = 0.006) after AC services. These findings may be utilized to develop DOAC and warfarin AC services.

Pharmacist-Managed Anticoagulation Services for Warfarin Management in Tertiary Hospitals: The Egyptian Experience

Background: Warfarin is widely regarded as the main anticoagulant in lowering the risk of thromboembolism. This study used indicators to compare pharmacist-managed anticoagulation services, using a well-prepared protocol, with physician-managed anticoagulation services. Methods: A retrospective prospective pilot study was conducted to compare patient outcomes before and after transitioning patients to pharmacist-managed anticoagulation services, comparing the proportion of those with therapeutic international normalized ratio (INR), subtherapeutic INR, and supratherapeutic INR, as well as their bleeding occurrences as indicators of assuring quality care. Results: A significant improvement in anticoagulation management was noted in the transition to pharmacist-managed anticoagulation services. The proportion of those with subtherapeutic INR decreased from 61.8% to 11.8% (p &lt; 0.001), those with supratherapeutic INR decreased from 20.6% to 2.9% (p &lt; 0.001), those with therapeutic INR increased from 17.6% to 85.3% (p &lt; 0.001), and the occurrence of bleeding decreased from 11.8% to 0.0%, without significant difference in warfarin doses (median from 4 before the transition to 5 after); in addition, the time to reach therapeutic INR decreased from 12-24 weeks to 2-8 weeks after transitioning to pharmacist-managed anticoagulation services. Conclusion: Pharmacist-managed anticoagulation services are considered safer and more effective than physician-managed anticoagulation services alone in terms of patients’ adherence and satisfaction, which provide an excellent opportunity for quality assurance care.

Tele-pharmacy Anticoagulation Clinic During COVID-19 Pandemic: Patient Outcomes.

Introduction: It is well-established that clinical pharmacist-managed anticoagulation services achieve superior anticoagulation control, with a positive impact. At King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, the structure of anticoagulation management is a pharmacist-managed specialty service. With the current COVID-19 situation, measures were taken to assure the continuity of patient care by establishing tele-pharmacy anticoagulation clinics.Materials and Methods: This was a prospective study with patients prescribed anticoagulation and followed up for 3 months. Since establishing the anticoagulation virtual clinic in March 2020, 270 patients were recruited in the study. The data collected included age, gender, comorbidities, indication for anticoagulation, intended duration of treatment, warfarin dose, testing of International Normalized Ratio (INR), INR target, range of INR values, time INR that was within the therapeutic range (TTR), and complications of therapy (bleeding and/or bruises). The patients were asked to complete the pharmacist satisfaction survey (PSS) after their consultation to assess patient satisfaction with the new virtual consultation system. Linguistic and cultural validation was conducted for the questionnaire.Results: A total of 270 patients were included in the study. The mean percentage of overall INR values in the range was 59.39% ± 32.84, and the mean time with the overall INR was within the therapeutic range 57.81% ± 32.08. Thirty-one percent of the sample had good anticoagulation control (time in therapeutic range >70%). The median satisfaction score was 32 (IQR 28–36) with a maximum score of 40.Conclusion: This is the first study to assess the tele-pharmacy anticoagulation clinic’s efficiency and patient satisfaction in Saudi Arabia during the COVID-19 pandemic. This type of consultation was as effective as face-to-face consultations. The study also highlighted that though the reduction in the cost of care was not substantial, there was a significant increase in resource (clinical pharmacist) utilization as a result of this model. The adoption of tele-pharmacy resulted in time savings for the clinical pharmacists who can be utilized in many other improvement projects in adult ambulatory clinics to ensure the delivery of better quality and safe patient care.

Effects of a pharmacist-managed anticoagulation outpatient clinic in Taiwan: evaluation of patient knowledge, satisfaction, and clinical outcomes

ABSTRACT Objective: The study aimed to evaluate the improvement of patient knowledge of warfarin use, satisfaction with pharmacists, and the quality of international normalized ratio (INR) control after the implementation of an anticoagulant clinic (ACC) service. Methods: This was a prospective single-group pre- and post-comparison study. Patients who were at least 20 years of age and participated in a pharmacist-managed ACC service were enrolled from February 2012 to September 2015. Each participant completed a self-administered questionnaire before and after the ACC service to evaluate changes in warfarin knowledge. Another questionnaire was distributed after the ACC to evaluate participants’ satisfaction with the pharmacist service in the ACC. The INR levels before and after the ACC intervention were obtained to calculate the proportion of time spent in the therapeutic INR range (time in therapeutic range, TTR). Paired t-tests were used to compare changes in participants’ knowledge related to warfarin use. Multiple linear regressions were performed to explore the predictors associated with the participants’ knowledge scores and TTR after the ACC intervention. Results: One hundred and forty-eight participants were enrolled in this study. A significant improvement (31.5%,p<0.001) in the knowledge of warfarin use was observed at the end of the ACC intervention. The interaction between warfarin and food was the most confusing factor for participants in warfarin use. More than 95% of the participants perceived a positive value of the pharmacist-managed ACC service. However, the consultation fee was the least satisfactory of the ACC service. The average TTR increased from 51.0±34.3% to 78.6±24.5% (p<0.001) after the ACC service was implemented. Participants’ education levels and baseline knowledge scores were significant determinants associated with the knowledge improvement in the appropriate warfarin use (p<0.001). Conclusions: A pharmacist-managed ACC improved patient knowledge of warfarin use and INR control, and led to high satisfaction with the pharmacist service in the ACC in Taiwan. Pharmacists should focus on patients with lower education levels to facilitate their understanding of the appropriate warfarin use for better health outcomes.

Appointment attendance and patient perception of drive-up INR testing in a rural anticoagulation clinic during the COVID-19 pandemic.

IntroductionThe Anticoagulation Forum and Centers for Disease Control and Prevention (CDC) recommend drive‐up international normalized ratio (INR) testing to combat INR non‐adherence and increase safety during the coronavirus disease 2019 (COVID‐19) pandemic. Patient perceptions and impact on attendance have not been studied.ObjectiveTo assess appointment volume and patient perception after initiation of drive‐up INR testing in a rural pharmacist‐managed anticoagulation clinic.MethodsThis cross‐sectional cohort survey study offered each patient attending the anticoagulation clinic via drive‐up or in‐office visit a survey between May 27 and July 2, 2020. Patients testing off‐site were excluded. Study end points included monthly patient volume, visit type preference, testing barriers, desired drive‐up duration, and overall clinic satisfaction. Clinic appointment volume from October 2019 to June 2020 was collected retrospectively through a schedule review.ResultsSixty‐four (80%) of 80 surveys offered were completed: 46.6% of respondents preferred drive‐up testing, 26.7% indifferent, and 26.7% preferred in‐office visits; 38.7% of respondents indicated a greater likelihood of continuing routine INR monitoring via drive‐up testing. Of the respondents completing the survey curbside, 46% and 27% of respondents identified reduced COVID‐19 transmission risk and ease of transportation as benefits of drive‐up INR testing, respectively. March and April clinic volumes were 19% and 22% below average, respectively, returning to baseline after drive‐up testing was implemented. Clinic rating before and after drive‐up testing remained high at 2.75 on a scale of 0‐3. While infection risk was identified as the biggest barrier to care by 32.8% of respondents, 59.3% of all respondents wanted drive‐up testing to continue indefinitely.ConclusionsDrive‐up INR testing improves patient attendance during the COVID‐19 pandemic. Patient perception of drive‐up testing is positive. About 46% of respondents preferred drive‐up INR testing with telehealth follow‐up and 59.3% of respondents want drive‐up testing to continue indefinitely, which suggests this approach to INR testing as a potential method to allay barriers to routine monitoring beyond the scope of the pandemic.

The Joint Physician- and Pharmacist-Managed Anticoagulation Clinic is Aiming to Improve Warfarin Management in Outpatients with Atrial Fibrillation in China

Background: Anticoagulation clinic (AC) is aimed at improving anticoagulation control and outcomes in patients with atrial fibrillation (AF). There is little published data on the benefits of providing an AC in China even if Asians have a higher risk of hemorrhage and stroke when taking warfarin. This study attempts to assess the impact of the AC on warfarin management in the Chinese population. Subjects and Methods: This prospective observational study was conducted in the First Affiliated Hospital of Nanjing Medical University and consecutively enrolled 42 AF patients from the joint physician-and pharmacist-managed AC from March 2017 to April 2018. The study protocol was approved by the Institutional Review Board of the First Affiliated Hospital of Nanjing Medical University. Patients already on warfarin for at least 6 months before coming to the AC and unwilling to receive AF ablation or switch to non-Vitamin K antagonist oral anticoagulants were included. The anticoagulant activity of warfarin was monitored using the international normalized ratio (INR). The primary outcome of this study was INR control, which was defined by the time-in-therapeutic range (TTR). The TTR before and after visiting the AC was compared. Results: The mean age of the enrolled 42 patients was 68.3 ± 10.6 years and 25 (59.5%) were women. The mean CHA2DS2-VASc score and the mean HAS-BLED score were 3.43 ± 1.29 and 1.86 ± 0.80, respectively, in 28 (66.7%) patients with nonvalvular AF. The median follow-up time after visiting the AC was 298.5 days (interquartile range: 151.8–441.8 days). The TTR (% days) before and after visiting the AC was 44.1% ± 27.5% and 69.7% ± 23.3% (P &lt; 0.001), respectively. Meanwhile, 6 (14.3%) and 25 (59.5%) patients had TTR (% days) &gt;65% before and after visiting the AC (P = 0.001), respectively. Conclusions: TTR values were higher in AF patients taking warfarin after the AC. More patients reached satisfactory warfarin control after visiting the AC.

Impact of an extended International Normalized Ratio follow-up interval on healthcare use among veteran patients on stable warfarin doses.

To analyze the impact of a 12-week extended International Normalized Ratio (INR) follow-up interval on healthcare use. A prospective cohort study of the use of an extended INR follow-up interval of up to 12 weeks was conducted over 2 years in a pharmacist-managed anticoagulation clinic. A detailed protocol was used to extend the INR follow-up interval to 5-6 weeks and then 7-8 weeks and 11-12 weeks. The number of planned and unplanned anticoagulation encounters, procedures requiring warfarin interruption, telephone triage phone calls, emergency department visits, and hospitalizations were collected. A post hoc subanalysis was also completed on participants who were scheduled for 4 consecutive 12-week intervals. Compared to baseline, at 12 months there was a mean decrease in planned anticoagulation encounters of 2.24 visits (p < 0.001) among 44 participants. From 12 to 24 months compared to baseline, there was a mean decrease in planned anticoagulation encounters of 3.13 visits (p < 0.001) and an increase of 0.54 unplanned anticoagulation encounters (p = 0.04) among 39 participants. The remainder of healthcare use variables were not statistically significantly different from baseline at any time point. Of the 15 participants scheduled for 4 consecutive 12-week intervals, there was a decrease from baseline of approximately 5 visits over the course of a year (p < 0.001). An extended INR follow-up interval appears to decrease anticoagulation healthcare use without an increase in acute healthcare use. While this intervention could be cost-effective, institutions need to consider safety, efficacy, and feasibility prior to implementation.

Impact of an electronic medium delivery of warfarin education in a low income, minority outpatient population: a pilot intervention study

BackgroundWarfarin is classified as a high-alert medication for ambulatory healthcare and safe guards for high-alert medications are necessary, including the practice of mandatory patient education. The high cost of hospitalizations related to adverse events combined with the average bleeding event rate of 7–8% in spite of routine patient education, suggests the importance of new approaches to standardized health education on warfarin. We sought to evaluate the impact of a warfarin educational video using an electronic tablet on patient knowledge and to determine patients’ satisfaction with the use of an electronic tablet for educational purposes in outpatient clinics serving a low income, minority population.MethodsA warfarin educational video delivered on an electronic tablet (iPad) was delivered at two pharmacist-managed anticoagulation clinics to uninsured patients whose annual income is equal or less than two hundred percent below the poverty level were offered. Patients (n = 18) completed a pre-video and post-video knowledge test on warfarin before and after viewing the warfarin educational video on an electronic tablet and a follow-up test to measure the retention of knowledge and a patient satisfaction survey at 60 days. The primary outcome was change in knowledge test scores. Other outcome measures included adherence rates, adverse events, time in therapeutic INR range, and patient-reported satisfaction scores.ResultsThe majority of patients were uninsured men taking warfarin for atrial fibrillation (n = 5). The median scores at post-video knowledge test and follow-up knowledge test were significantly higher than that for the pre-knowledge test (12 (11–12) vs. 10(8–11), p < 0.001). The study group had a ‘time in therapeutic INR’ range of 56.3%, a rate of adverse events of 24.5%, and a self-reported adherence rate to warfarin of 94.1%. The majority of patients also had positive responses to the patient satisfaction survey.ConclusionsPatient education delivered via iPad to facilitate knowledge of medication can serve as a useful tool for educating patients about warfarin and warfarin therapy. Use of an electronic medium may be a unique way to provide standard medication education to patients.Trial registrationThe study was retrospectively registered with: NCT03650777; 9/18/18.

Evaluation of the potential impact of pharmacy technician performance of anticoagulation clinic tasks on operational efficiency.

Results of a study to determine the proportion of anticoagulation clinic workload that could be performed by clinical pharmacy technicians (CPTs) and the potential impact on operational efficiency of pharmacist-managed anticoagulation clinics (ACCs) are reported. In a quality improvement project involving 11 Veterans Affairs (VA) medical centers, investigators conducted a 3-day time study in pharmacist-managed ACCs followed by scoring of task appropriateness for CPTs via the RAND/UCLA appropriateness method by the VA Anticoagulation Subject Matter Expert (SME) Workgroup. The primary outcome was the percentage of tasks deemed appropriate for a CPT to perform. The Anticoagulation SME Workgroup determined that a wide variety of mainly administrative ACC tasks could be completed by a CPT. At the 11 VA ACCs, an average of 53.4% (range, 39.9-76.1%) of tasks being performed by pharmacists were deemed appropriate for CPTs. The average percentage of total clinic time associated with performing tasks appropriate for a CPT equated to an estimated 1,111 hours per year. Shifting that portion of the annual work hours to a CPT could potentially result in cost avoidance of $55,302. At the ACCs evaluated, a significant proportion of tasks (53.4% on average) may be appropriate to assign to CPTs to improve the operational efficiency of these clinics. This finding supports development of business plans for the addition of CPTs in ACCs along with elements to inform crafting of an effective template for ACC structure, including clearly defined CPT roles.

Abstract 242: Comparison of Pharmacist-Managed Initial Dosing of Direct Oral Anticoagulants with Non-Pharmacist Practitioner Prescribing Patterns

Background: There is currently a lack of data regarding pharmacist-managed DOAC (direct oral anticoagulant) therapy. The objective of this study was to assess the impact of pharmacist-managed initial dosing of apixaban and rivaroxaban utilizing a Pharmacy and Therapeutics Committee approved guideline when compared with general practitioner/cardiologist practitioner prescribing practices for patients with Non-Valvular Atrial Fibrillation (NVAF). Methods: A retrospective, chart review was performed during the period of January 2015 to January 2018 and included adults 18-95 years old, who were prescribed apixaban or rivaroxaban for documented NVAF. Patients eligible for this study were split up into two cohorts: a pharmacist-managed cohort and a non-pharmacist-managed cohort. The primary endpoint of the study was the percentage of patients who received appropriate initial apixaban or rivaroxaban dosing. Any incorrect initial doses of apixaban or rivaroxaban were then analyzed to determine the reason for error. The secondary endpoints included thromboembolic and hemorrhagic adverse events. Exploratory analyses included: provider follow up-time, inappropriate DOAC use in valvular atrial fibrillation (VAF), and correct transition from warfarin to DOAC. Results: For the primary endpoint, the pharmacist practitioner was significantly more accurate when initially dosing apixaban and rivaroxaban compared to non-pharmacist practitioners (97% [63 out of 65] vs. 74% [48 out of 65] correct prescriptions, p=0.001). When evaluating the reason for error in prescribing, non-pharmacist providers were significantly less likely to dose the patient appropriately based on renal function or drug interactions (p=0.003). For the secondary endpoint of hemorrhagic or thromboembolic events, there were no statistically significant differences among the two provider types. The exploratory analyses revealed that 3% (2 out of 65) of the patients in the non-pharmacist managed cohort had VAF and received a DOAC for antithrombotic therapy. The patients in the pharmacist managed cohort had zero patients receive a DOAC for VAF. The pharmacist was also significantly better at transitioning patients from warfarin to DOACs correctly compared to non-pharmacist practitioner (100% [12 out of 12] vs. 50% [3 out of 6], p=0.025) and following up with patients within a four-month time frame compared to non-pharmacist practitioners (100% [65 out of 65] vs. 82% [53 out of 65], p=0.001). Conclusion: Additional research is required to evaluate the benefits of pharmacist-managed anticoagulation; however, based on the results of this study, pharmacists are significantly better equipped to initiate DOAC therapy for patients with NVAF. Based on the findings of the study results, pharmacist-managed DOAC services may be transferrable to a variety of different disease states requiring anticoagulation therapy.

Preemptive Dose Adjustment Effect on the Quality of Anticoagulation Management in Warfarin Patients With Drug Interactions: A Retrospective Cohort Study.

One strategy to manage patients on warfarin starting an interacting drug is to increase the frequency of monitoring. Another strategy is to adjust warfarin dose around the time patient is started on an interacting medication, which is known as “preemptive warfarin dose adjustment.” The main objective of this study is to compare preemptive to nonpreemptive strategy and their impact on the quality of anticoagulation management. This is a retrospective cohort study performed at the pharmacist-managed anticoagulation clinic in a tertiary hospital in the State of Qatar. Over a 4-year period, 340 patients were evaluated, and 58 warfarin–drug interaction encounters were identified. Mean age of the patients was (57.7 ± 13.7), and 50% of them were females. Preemptive dose adjustment was used in 17 (29.3%) cases. Incidence of out-of-target international normalized ratio (INR) was statistically lower in the preemptive arm compared to the control group (41.2% [7/17] vs 69.2% [27/39], P = .048). Incidence of extreme out-of-target INR was numerically lower in the preemptive arm compared to the control but did not reach statistical significance (11.8% [2/17] vs 29.3% [12/41], P = .139). Change in frequency of INR monitoring was not different between the 2 groups. However, overall frequency of INR monitoring after onset/discontinuation of interacting medication increased compared to baseline (7 [9] vs 21 [16] days, P < .001). Preemptive strategy was shown in our study to decrease incidence of the out-of-target INR visits, although patients remained in need for close monitoring.

Institution-based, Pharmacist-managed Anticoagulation in Patients with a Left Ventricular Assist Device

Long-term anticoagulation with warfarin is required for patients with left ventricular assist devices (LVADs). There is limited data of time in therapeutic range (TTR) in the LVAD population, with reports of 31% to 52%. We sought to evaluate the TTR for an institution-based, pharmacist-managed anticoagulation clinic in the LVAD population.

Interventions and Strategies to Improve Oral Anticoagulant Use in Patients with Atrial Fibrillation: A Systematic Review of Systematic Reviews.

Anticoagulation therapy is the fundamental approach for stroke prevention in atrial fibrillation (AF) patients. Numerous systematic reviews comparing anticoagulation strategies have been published. We aim to summarize the efficacy and safety evidence of these strategies in AF patients from previously published systematic reviews. We searched PubMed, EMBASE and Cochrane library from inception to Feb 24th, 2017, to identify systematic reviews and meta-analyses of randomized controlled trials that assessed interventions or strategies to improve oral anticoagulant use in AF patients. Thirty-four systematic reviews were eligible for inclusion but only 11 were included in the qualitative analyses, corresponding to 40 unique meta-analyses, as the remaining systematic reviews had overlapping primary studies. There was insufficient evidence to support the efficacy of genotype-guided dosing and pharmacist-managed anticoagulation clinics for stroke prevention in AF patients. Conversely, patient's self-management and novel oral anticoagulants (NOACs), in general were superior to warfarin for preventing stroke and reducing mortality. All interventions showed comparable risk of major bleeding with warfarin. Findings from this overview support the superiority of NOACs and patient's self-management for preventing stroke in AF patients. However, uncertainties remain on the benefits of genotype-guided dosing and pharmacist-managed anticoagulation clinics due to poor quality evidence, and future research is warranted.

Pharmacist-managed Warfarin in Pediatric Cardiac Patients: Quality-improvement Study

Objective: To compare the efficacy of warfarin management by a pharmacist-managed group to a cardiologist-managed group (usual care) in an outpatient pediatric population. Methods: Fourteen patients with an international normalized ratio (INR) goal determined by a cardiologist were included. The pharmacist-managed group included twelve patients. There were seven patients in the cardiologist-managed group. Prior to the transition to a pharmacist-managed service in September 2014, cardiologists managed anticoagulation. For the cardiologist-managed group, INR values were recorded for six months. Following a washout period of three months, INR values were obtained for the pharmacist-managed group for the subsequent six months. Patients were included in each analysis if they were followed for more than 3 months. A protocol guided dose adjustments, recommended monitoring, and allowed for pharmacist-managed warfarin. Results: The median number of INR tests per patient was not significantly lower in the cardiologist-managed group compared to the pharmacist-managed group (28 versus 36 measurements, p=0.06). The median percentage of time in therapeutic range using the Rosendaal method was not significantly higher in the pharmacist-managed group compared to the cardiologist-managed group (55.5% versus 54%, p=0.93). The median percentage of values in therapeutic range using the traditional method was also not significantly higher in the pharmacist-managed group compared to the cardiologist-managed group (41.9% versus 36.8%, p=0.93). Conclusion: Warfarin management in a pharmacist-managed group compared to a cardiologist-managed group provided similar care. Differences in time in therapeutic range and median values in therapeutic range were not found between the pharmacist-managed group and cardiologist-managed group. These results describe and provide support that pharmacist-managed anticoagulation of pediatric cardiology patients is safe and effective in the outpatient setting.

Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service

BackgroundClinical pharmacy anticoagulation services have improved the quality of anticoagulant therapy and are associated with lower rates of bleeding and thromboembolism compared to usual care. Several studies have found that higher time-in-therapeutic range (TTR) during warfarin therapy is associated with better warfarin outcomes. However, whether increasing TTR over time within an established anticoagulation service is associated with further reduction in bleeding and thromboembolic outcomes is unknown. MethodsThis was a retrospective cohort study of patients with atrial fibrillation conducted at an integrated healthcare delivery system with a centralized, pharmacist-managed anticoagulation service. Clinical outcomes (clinically-relevant bleeding, ischemic stroke or systemic embolism, and all-cause mortality) and TTR were compared between two distinct time periods: 1/1/2006 through 12/31/2007 (control group) and 1/1/2012 through 12/31/2013 (observation group) with regression modeling to adjustment for potential confounders. ResultsThere were 3641 and 4764 patients in the control and observation groups, respectively. The mean age was 74.3 years and 54.4% of the cohort was female. Mean TTR was higher in the observation group (70.5% vs. 63.4%, p < 0.001). The composite outcome of clinically-relevant bleeding, thromboembolism and all-cause mortality occurred in 4.6% and 3.6% of the control and observation groups, respectively (adjusted odds ratio = 0.69; 95% confidence interval 0.54–0.87). Individual rates of stroke/systemic embolism and all-cause mortality were each lower in the observation group (both p < 0.05) while clinically-relevant bleeding was not significantly different (p = 0.256). ConclusionIncreased TTR within a clinical pharmacy anticoagulation management service was associated with a lower risk of the composite outcomes of bleeding, thromboembolism and death in a large atrial fibrillation population receiving warfarin.

Assessment of oral anticoagulation control at two pharmacist-managed clinics in Brazil.

Background Warfarin remains widely used by patients with cardiovascular diseases. When using warfarin, the quality of oral anticoagulation control is a critical determinant to minimize the risk of bleeding and thromboembolic events. Pharmacist engagement in patient care is relevant towards improving the quality of warfarin therapy. Objective To assess the quality of oral anticoagulation control measured by time in therapeutic range (TTR) at two pharmacist-managed anticoagulation clinics (AC). Method This study included adults with indication of continuous warfarin use. Patients were recruited at two AC of public hospitals in Brazil (2014-2015). Anticoagulation control was assessed by TTR using the Rosendaal method. Laboratory INR values were collected for the maximum period of follow-up (2009-2015). Results A total of 554 patients were studied. The median age was 63.7 [Quartile 1 (Q1) 54.3; Quartile 3 (Q3) 73.6] years, 57.4% female. The median TTR was 64.3% [Q1 54.0%; Q3 74.0%], and 344 (61.6%) patients had TTR≥60%. Conclusion Pharmacist-managed AC have achieved an adequate TTR in Brazilian patients with low socioeconomic status. Interventions include face-to-face appointments for individual patient education, warfarin-dosing adjustments and monitoring of drug interactions. Pharmacists are important to improve adherence and the quality of warfarin therapy in low- and middle income countries.

Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review.

To perform a systematic review to evaluate the quality of warfarin anticoagulation control in outpatient pharmacist-managed anticoagulation services (PMAS) compared with routine medical care (RMC). MEDLINE, SCOPUS, EMBASE, IPA, CINAHL, and Cochrane CENTRAL, from inception to May 2017. Search terms employed: ("pharmacist-managed" OR "pharmacist-provided" OR "pharmacist-led" OR "pharmacist-directed") AND ("anticoagulation services" OR "anticoagulation clinic" OR "anticoagulation management" OR "anticoagulant care") AND ("quality of care" OR "outcomes" OR "bleeding" OR "thromboembolism" OR "mortality" OR "hospitalization" OR "length of stay" OR "emergency department visit" OR "cost" OR "patient satisfaction"). Criteria used to identify selected articles: English language; original studies (comments, letters, reviews, systematic reviews, meta-analyses, editorials were excluded); warfarin use; outpatient setting; comparison group present; time in therapeutic range (TTR) included as a measure of quality of anticoagulant control; study design was not a case report. Of 177 articles identified, 25 met inclusion criteria. Quality of anticoagulation control was better in the PMAS group compared with RMC in majority of the studies (N = 23 of 25, 92.0%). Clinical outcomes were also favorable in the PMAS group as evidenced by lower or equal risk of major bleeding (N = 10 of 12, 83.3%) or thromboembolic events (N = 9 of 10, 90.0%), and lower rates of hospitalization or emergency department visits (N = 9 of 9, 100%). When reported, PMAS have also resulted in cost-savings in all (N=6 of 6, 100%) of studies. Compared with routine care, pharmacist-managed outpatient-based anticoagulation services attained better quality of anticoagulation control, lower bleeding and thromboembolic events, and resulted in lower health care utilization.