Impact of a pharmacist-managed anticoagulation clinic on clinical events

Abstract

BackgroundAnticoagulation management services (AMSs) are widely used for anticoagulation management in many countries. Our AMS is a pharmacist-run ambulatory clinic with a physician advisory committee that manages patients referred with complicated anticoagulation histories. This paper assesses the adequacy of anticoagulation, rates of anticoagulant-related events and associated health care resource utilization for patients before and after referral to our AMS.MethodsConsecutive patients referred to the AMS with 4 months of prior anticoagulation management who also had anticoagulation management for 4 months within the AMS were included in the evaluation. The primary endpoint was adequacy of anticoagulation (target international normalized ratio [INR] ± 0.5). Secondary outcomes included adverse events requiring an emergency department (ED) visit or hospital stay. These were classified by International Classification of Diseases (ICD) codes as thromboembolic, hemorrhagic, or non-anticoagulant related. Health care system resource consumption data were collected as number of hours spent in an ED and hospitalization costs.ResultsA total of 125 patients were included: 57.6% were male, with a mean age of 62.9 (standard deviation [SD]) ± 15.0 years. Indications for warfarin therapy were atrial fibrillation (40.0%), mechanical valve replacement (24.0%) and venous thromboembolism (19.2%). The adequacy of anticoagulant control was significantly greater during AMS care compared with the period before referral; patients were in the target INR range 66.5% versus 48.8% of the time, respectively (95% confidence interval [CI] 13.4%–22.0%; p < 0.0001). The relative risk of a thromboembolic event before referral to AMS care was 17.6 (95% CI 6.0–51.9; p < 0.0001), while the relative risk of a hemorrhagic event before AMS care was 1.6 (95% CI 0.7–3.7; p = 0.25). During AMS care, savings included 572 hours in the ED and Cdn$122,145.40 in hospitalization costs.ConclusionsA pharmacist-directed, physician-supported AMS program achieved significantly better INR control and reduced rates of thromboembolic complications compared with standard care. Resource utilization was substantially reduced during AMS care.

Evidence-Based Management of Anticoagulant Therapy

“…45,48 In contrast, the results of many low-quality observational studies have reported higher TTR and better outcomes in patients when anticoagulant therapy is managed by an AMS compared with usual care. [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65] The absolute difference in TTR between AMS and pletion. 67 THINRS was more promising in that ‫ف‬ 80% were able to pass a PST competency assessment, but 16% switched from PST to the clinic testing group during the study.…”

Development and implementation of a pharmacist-managed outpatient parenteral antimicrobial therapy program

“…[13][14][15][16][17][18][19][20] There is evidence that clinical outcomes in patients receiving care within pharmacist-managed programs are either comparable 14,20 or superior 18,19 to those achieved in physician-managed programs. The increasing use of OPAT as a cost-saving measure provides a prime opportunity for pharmacists to become involved in this form of care.…”

Dabigatran in Atrial Fibrillation: New Kid on the Block

“…7 In contrast, warfarin's anticoagulation is due to its indirect effects on the clotting cascade, taking several days to inhibit hepatic synthesis of vitamin K-dependent clotting factors. 5 Its full anticoagulant effects are not realized until circulating clotting factors are eliminated.…”

“…3,4 However, maintaining warfarin therapy within its narrow therapeutic window is challenging, even for specialized anticoagulation clinics. 5 Many factors contribute to the variable dose response of warfarin, such as inter-individual variability, comorbidities and drug and food interactions. 5 Dabigatran is a novel therapeutic alternative that provides more predictable anticoagulation with less laboratory monitoring, and it is poised to take over some of warfarin's role in AF stroke prophylaxis.…”

“…5 Many factors contribute to the variable dose response of warfarin, such as inter-individual variability, comorbidities and drug and food interactions. 5 Dabigatran is a novel therapeutic alternative that provides more predictable anticoagulation with less laboratory monitoring, and it is poised to take over some of warfarin's role in AF stroke prophylaxis. While other novel agents, such as rivaroxaban and apixaban, have proven to be beneficial in stroke prophylaxis in AF, discussion of their roles is beyond the scope of this article.…”