Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics

Abstract

Background While systematic anticoagulation management leads to improved outcomes, there is limited data comparing outcomes in anticoagulation clinics managed by pharmacists vs nurses. The objective of this study was to evaluate the effect of pharmacist vs nurse‐managed clinics on the quality of anticoagulation and warfarin‐related hospitalizations and emergency department (ED) admissions. Methods A retrospective observational cohort study of patients treated with warfarin and referred to a pharmacist‐managed anticoagulation clinic (PMAC) or a nurse‐managed anticoagulation clinic (NMAC) was conducted at the University of Illinois Hospital and Health Sciences System. The primary outcome was the proportion of international normalized ratio levels in therapeutic range (PIR). The secondary outcome was warfarin‐related hospitalizations and ED visits. Multivariate regression models were used to evaluate the effect of the model of care (PMAC vs NMAC) on PIR and hospitalization/ED visits, respectively. An economic evaluation of adverse events was also undertaken. Results A total of 200 consecutive patients (100 patients in the PMAC group and 100 patients in the NMAC group) were included. The majority of patients were females (58.5%) and average age was 61.4 ± 14.6 years. Patients in the PMAC group were more nonadherent to warfarin therapy and had more than three missed clinic appointments compared with the NMAC group ([19.1% ± 10.1% vs 4.1% ± 4.1%, P < 0.05]; and [78% vs 33%, P < 0.05]) respectively. The average PIR was 51.8% ± 15.9% and 56.2% ± 13.9% (P = 0.04) in the PMAC and NMAC groups, respectively. After controlling for confounders, the adjusted PIR was not different between the two groups. The NMAC group, however, had over seven times greater odds of hospitalization/ED visits compared to the PMAC group. The PMAC saved $505 349 over a 1.25 year period. Conclusion The quality of warfarin anticoagulation did not differ between pharmacist and nurse‐managed models of anticoagulation care, however, PMACs decreased the odds of warfarin‐related hospitalizations/ED visits and their associated costs.

The future of anticoagulation management services: Ensuring and expanding patient access to pharmacists' care

“…Manzoor and colleagues did not note a difference in anticoagulation control between the pharmacist and the nurse AMS model. However, patients in the pharmacist AMS had a comparatively lower odds of experiencing a hospitalization or emergency department visit, leading to a cost avoidance of nearly $5000 per patient over 1.25 years . In combination, these studies further demonstrate that pharmacist AMS result in an improvement in quality outcomes and a reduction in health care utilization over other models.…”

“…In this issue of the Journal of the American College of Clinical Pharmacy, there are two studies evaluating warfarin management in pharmacist-run AMS compared with nurse-run models. 5,6 Tarasiuk and colleagues found that fewer all-cause hospitalizations occurred with pharmacist-vs nurse-managed AMS. 5 Patients in the pharmacist AMS also had a significantly higher measure of anticoagulation control compared with those in the nurse AMS.…”

“…In this issue of the Journal of the American College of Clinical Pharmacy , there are two studies evaluating warfarin management in pharmacist‐run AMS compared with nurse‐run models . Tarasiuk and colleagues found that fewer all‐cause hospitalizations occurred with pharmacist‐ vs nurse‐managed AMS .…”

Cardiology clinical pharmacy practice: Keep spreading the news!

“…This issue of JACCP contains several papers demonstrating that pharmacists impact and improve patient care. Compared to nurse‐managed programs, pharmacist‐managed anticoagulation services were associated with reduced hospitalization rates in two studies, decreasing costs by more than $500 000 at one institution . In patients with acute coronary syndrome, inclusion of pharmacists in both shared decision‐making for the selection of antiplatelet therapy and transitions of care were associated with a high frequency of patient‐centered interventions and lower rates of rehospitalization …”

“…Compared to nurse-managed programs, pharmacistmanaged anticoagulation services were associated with reduced hospitalization rates in two studies, decreasing costs by more than $500 000 at one institution. 8,9 In patients with acute coronary syndrome, inclusion of pharmacists in both shared decision-making for the selection of antiplatelet therapy and transitions of care were associated with a high frequency of patient-centered interventions 10 and lower rates of rehospitalization. 11 Given the dynamic nature of health care today and the fragile financial status of many medical centers, the profession of pharmacy, in general, and cardiology clinical pharmacy specialists, in particular, need to work together to continue to produce high-quality evidence demonstrating our value regarding clinical, economic, and humanistic outcomes.…”