Risk Factors for Excessive Anticoagulation Among Hospitalized Adults Receiving Warfarin Therapy Using a Pharmacist‐Managed Dosing Protocol

Berg, Tamara M.; O’Meara, John G.; Ou, Narith N.; Daniels, Paul; Moriarty, James P.; Bergstrahl, Eric; Dierkhising, Ross A.; Manning, Dennis M.

doi:10.1002/phar.1280

Cited by 12 publications

(12 citation statements)

References 14 publications

(26 reference statements)

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“…In 2012, the first study using a detailed dosing schedule for both the initiation and continuation of warfarin was published . That study and many other published literatures may be ideal references for detailed dosing recommendations and pharmaceutical care detailed.…”

Section: Discussionmentioning

confidence: 99%

Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

et al. 2016

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What is known and objective: Anticoagulation management services are well known to improve the quality of patient care and to reduce the rates of hospitalization and emergency department visits following adverse events related to anticoagulation therapy. The complexity of managing warfarin has led to the development of a variety of specialized models managed by pharmacists, physicians, nurses, and self-managed care. The aim of the study is to compare the effectiveness of pharmacistmanaged anticoagulation control of warfarin with other models. Methods: We performed a systematic literature search of the PubMed, Medline@Web of Knowledge, EMBASE, Cochrane Library and Cumulative Index to Nursing and Allied Health Literature to identify randomized controlled trials (RCTs) from database inception up to July 2015. The search terms used for the study were 'warfarin', 'pharmacists', 'Vitamin K antagonist', 'anticoagulation' and 'management model.' We used the Cochrane Collaboration's tool from the Cochrane Handbook to assess the risk of bias of RCTs. We performed statistical analyses using RevMan 5.3 and used the Grading of Recommendations, Assessment, Development, and Evaluations profiler to rate the quality of evidence of the outcomes. The anticoagulation control outcomes were the percentage of time within the standard and expanded therapeutic range and thrombosis events; the safety outcomes were bleeding events and mortality, and patients' satisfaction of anticoagulation service. Results and discussion: Eight RCTs from 981 potentially relevant publications with a total of 1493 patients were included. Meta-analysis of the RCTs showed that a significant difference existed between pharmacist-managed care and other models for satisfaction (mean difference (MD) = 0Á41, 95% CI, 0Á01-0Á81, P = 0Á04, low-quality evidence) with heterogeneity, and the percentage of time within the standard therapeutic range (MD = 3Á66, 95% CI 2Á20-5Á11, P < 0Á00001, high-quality evidence) without heterogeneity. However, the pharmacistmanaged group demonstrated no significant improvement on the percentage of time within the expanded therapeutic range (MD = 2Á85, 95% CI À0Á56 to 6Á26, P = 0Á10, moderate-quality evidence) with heterogeneity, mortality [odds ratio (OR) = 0Á97, 95% CI, 0Á44-2Á11, P = 0Á09, high-quality evidence] without heterogeneity, the prevention of bleeding events (OR = 0Á89, 95% CI, 0Á56-1Á44, P = 0Á64, high-quality evidence) without heterogeneity, and thrombosis events (OR = 0Á81, 95% CI, 0Á34-1Á92, P = 0Á64, high-quality evidence) without heterogeneity. What is new and conclusion: The advantage of pharmacistmanaged warfarin anticoagulation therapy in terms of anticoagulation control, safety and mortality are unclear, but resulted in significantly better patient satisfaction. Compared with other models, the superiority of pharmacist-managed warfarin anticoagulation needs to be further evaluated and validated in future research. WHAT IS KNOWN AND OBJECTIVEWarfarin has become the most widely used oral anticoagulant since ...

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Section: Discussionmentioning

confidence: 99%

Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

et al. 2016

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“…The protocol underwent multiple revisions to arrive at the current version; this was published in 2013. 13 Given the primary aim of the project, our team prospectively monitored the performance of the protocol, analysing the cases in which patients on the protocol had an INR >5 to identify potential reasons for these defects. This information was then used in new iterations of the protocol.…”

Section: Methodsmentioning

confidence: 99%

“…Daily INR values were measured while on the protocol. 13 Warfarin dosing and the pharmacists’ notes are available to all providers in the electronic medical record.…”

Section: Methodsmentioning

confidence: 99%

Improving inpatient warfarin therapy safety using a pharmacist-managed protocol

et al. 2018

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IntroductionSafe management of warfarin in the inpatient setting can be challenging. At the Mayo Clinic hospitals in Rochester, Minnesota, we set out to improve the safety of warfarin management among surgical and non-surgical inpatients.MethodsA multidisciplinary team designed a pharmacist-managed warfarin protocol (PMWP) which designated warfarin dosing to inpatient pharmacists with guidance from computerised dosing algorithms. Ordering this protocol was ultimately designed as an ‘opt out’ practice. The primary improvement measure was frequency of international normalised ratio (INR) greater than 5; secondary measures included adoption rate of the protocol, a counterbalance INR metric (INR <1.7 three days after first inpatient warfarin dose), and complication rates, including bleeding and thrombosis events. An interrupted time series analysis was conducted to compare outcomes.ResultsAmong over 50 000 inpatient warfarin recipients, the PMWP was adopted for the majority of both surgical and non-surgical inpatients during the study period (1 January 2005 to 31 December 2011). The primary improvement measure decreased from 5.6% to 3.4% for medical patients and from 5.2% to 2.4% for surgical patients during the preimplementation and postimplementation periods, respectively. The INR counterbalance measure did not change. Postoperative bleeding decreased from 13.5% to 11.1% among surgical patients, but bleeding was unchanged among medical patients.ConclusionOur PMWP led to achievement of improved INR control for inpatient warfarin recipients and to less near-term bleeding among higher risk, surgical patients.

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“…Because HPAs can cause dangerously high INRs (>4.5) within two to six days of initiation, it is possible that many of these unmonitored patients had a clinically notable bleeding risk that was unknown to their providers. 3,12,24 FMEA identified over 130 specific failure modes potentially contributing to these adverse events (INR of >4.5 and bleeding events). This study was unique because it not only showed the possible consequences of administering warfarin with HPAs but also semiquantitatively established how to best intervene on the basis of a systematic analysis.…”

Section: Discussionmentioning

confidence: 99%

“…Trimethoprimsulfamethoxazole, metronidazole, fluconazole, voriconazole, and miconazole are considered HPAs because they inhibit CYP metabolism. [12][13][14] The interaction between warfarin and HPAs results in appreciably increased INRs and is frequently missed by outpatient warfarin monitoring programs. 11,[15][16][17][18] For example, the addition of trimethoprimsulfamethoxazole to warfarin therapy resulted in INR increases of ≥2 in more than one third of patients.…”

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confidence: 99%

Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy

Daniels

Barreto

Kuth

et al. 2015

American Journal of Health-System Pharmacy

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Risk Factors for Excessive Anticoagulation Among Hospitalized Adults Receiving Warfarin Therapy Using a Pharmacist‐Managed Dosing Protocol

Cited by 12 publications

References 14 publications

Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

Improving inpatient warfarin therapy safety using a pharmacist-managed protocol

Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy

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