Cost-justification of a clinical pharmacist-managed anticoagulation clinic

A cost-benefit evaluation of a clinical pharmacist-managed anticoagulation clinic (AC) was performed. Outpatient and hospital records were examined for 26 patients in the treatment group with an AC clinic and 26 patients in the control group. Therapeutic prothrombin times were maintained within the treatment group to a significantly greater extent than within the control group (p less than 0.001). The AC was successful in preventing hospitalizations resulting from hemorrhage or thromboembolism (p less than 0.01). The abnormal prothrombin times on admission in the control group correlated with hemorrhagic and thromboembolic admissions (p less than 0.05, p less than 0.005, respectively). Patients were hospitalized 3.22 days and .048 days per patient-treatment-year in the control and treatment groups, respectively. The net savings in reduced hospitalization costs per year in the treatment group was $211776. The benefit:cost ratio (B:C) was 6.55, suggesting the program is socially valuable. This clinical pharmacist-managed AC was effective in maintaining therapeutic prothrombin times, and reducing the incidence of hospitalization resulting from anticoagulation complications, and can be cost-justified based on a cost-benefit analysis.     

Nine-year experience with a pharmacist-managed anticoagulation clinic

A pharmacist-managed anticoagulation clinic is described, and information on patient outcome during a nine-year period is presented. Since 1974, a pharmacist has managed an anticoagulation clinic for ambulatory patients and inpatients at San Francisco General Hospital Medical Center. The pharmacist's primary responsibilities include the following: educating patients about their diseases and the importance of drug therapy, monitoring patients' vital signs, performing physical examinations, and adjusting warfarin dosage to maintain prothrombin times within the therapeutic range (1.7-2.5 times normal using control values of 1.0-1.2). These patients are also under the care of their primary physicians. The pharmacist's work is checked by the chief of the cardiac clinic at the end of each clinic session. The effectiveness of the pharmacist in managing clinic patients is reviewed periodically; from January 1975 through June 1984, the pharmacist had treated 140 patients (141 courses of therapy). Of 1792 prothrombin times taken during this time, 1060 (59.2%) were within the therapeutic range of 17-25 seconds, 510 (28.5%) were less than 17 seconds, and 222 (12.4%) were greater than 25 seconds. Only four major hemorrhagic events (0.002 hemorrhages per patient-treatment month) and 89 minor events (0.05 hemorrhages per patient-treatment month) occurred. The recurrence rate of thromboembolic events was 0.007 per patient-treatment month. Pharmacist-managed warfarin therapy in these clinic patients resulted in a level of anticoagulation control and morbidity that was acceptable to physicians.     

Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic

The effectiveness of a pharmacist-managed warfarin anticoagulation clinic in maintaining therapeutic prothrombin times and preventing hospitalizations secondary to inadequate control of anticoagulation was evaluated. Patients who had received warfarin sodium for at least one year before being referred to the anticoagulation clinic were studied using retrospective chart reviews. Clinical pharmacists provided patient education, monitored patients for hemorrhagic and thromboembolic complications, and adjusted warfarin sodium dosage to maintain therapeutic prothrombin times. The patients' primary physicians retained responsibility for overall care and were consulted by pharmacists regarding complications of anticoagulation and patient unreliability. The percentage of patients requiring hospitalization (39% versus 4%) and the percentage of prothrombin times outside the therapeutic range (35.8% versus 14.4%) were significantly higher during the preclinic phase (before referral to the clinic) than during the clinic phase. Eight patients were hospitalized for hemorrhagic complications and four for thromboembolism during the preclinic phase; only one hospitalization for hemorrhage occurred during the clinic phase. The warfarin anticoagulation clinic staffed by specially trained pharmacists provided improved therapy compared with treatment received by patients before their referral to the clinic.     

Outcomes of warfarin therapy managed by pharmacists via hospital anticoagulation clinic versus online anticoagulation clinic

Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital  to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P?=?0.393) and adverse events [major bleeding events (0 vs. 1.2%, P?=?1.000), minor bleeding events (10.0 vs. 9.8%, P?=?0.960), thromboembolic events (0 vs. 0%, P?=?1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P?=?1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P?=?1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P?=?0.148), and extreme total (8.4 vs. 5.8%, P?=?0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P?=?0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P?=?0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.     

Assessment of anticoagulation management in a simulated ambulatory care clinic

Objectives

To assess the effectiveness of adding a simulated anticoagulation clinic practical examination for formal assessment of PharmD students'' skills.

Design

A practical examination requiring students to review a mock medical record and role-play a follow-up anticoagulation clinic visit with a standardized patient was designed. Students assessed the patient''s vital signs, laboratory values, and subjective complaints during an in-depth interview and documented clinical recommendations in a progress note.

Assessment

Student feedback indicated that the simulated clinic was pertinent to preparation for experiential rotations. Ninety-five percent of the students recommended that it be continued as a required component of the course.

Conclusion

The simulated ambulatory care clinic exercise reinforces principles of anticoagulation management as well as the assessment of clinical data, performance of a patient interview, and written documentation of recommendations.     

Evaluation of a pharmacist vs. Haematologist-managed anticoagulation clinic: A retrospective cohort study

IntroductionWarfarin is the core component in the management of various thromboembolic disorders, which requires specialized expertise to optimize outcomes. There is limited data comparing a pharmacist vs. a haematologist-managed anticoagulation clinic in our setting, and in the Middle East. We aimed to evaluate the effectiveness and safety of a pharmacist vs. a haematologist-managed anticoagulation clinic in the Ambulatory Care Center at King Abdulaziz Medical City, Jeddah, Saudi Arabia.MethodsA retrospective cohort study was conducted from 2016 to 2018, which included adult patients who have been followed-up for at least six months and who received warfarin for an extended period. The primary outcome was the proportion of time the patients in the two arms were in the therapeutic range. The secondary outcomes were the differences in expanded time in the therapeutic range, as well as the frequency of bleeding and thromboembolic events between the two arms.ResultsWe enrolled 104 and 124 patients in the pharmacist and haematologist arms respectively. The median time in the therapeutic range for the pharmacist arm was 71.4%, IQR (60.8–83.8) vs. 65%, IQR (43.5–79.1), in the haematologist arm (p = 0.0049). The median expanded time in the therapeutic range was 86.4%, IQR (77.5–95.3) vs. 81.21%, IQR (67.1–93.3) in the pharmacist vs. haematologist arm (p = 0.015) respectively. Major bleeding events occurred in 5.7 % vs. 3.2 %, and thromboembolic events in 5.7% vs. 4%, in the pharmacist vs. haematologist arm respectively.ConclusionsOur results demonstrated that the time in the therapeutic range was significantly higher in the pharmacist arm, with no significant difference in bleeding and thromboembolic events compared to the haematologist arm.     

Quality of anticoagulation care in patients discharged from a pharmacist-managed anticoagulation clinic after stabilization of warfarin therapy

STUDY OBJECTIVE: To determine if transitioning patients from a pharmacist- managed anticoagulation clinic after stabilization of warfarin therapy to physician-managed care alters the quality of anticoagulation care. DESIGN: Retrospective medical record review. SETTING: Pharmacist-managed, urban academic medical center-based outpatient anticoagulation clinic. PATIENTS: Forty patients who were stabilized on warfarin therapy. MEASUREMENTS AND MAIN RESULTS: Quality of anticoagulation care was measured by percentage of international normalized ratios (INRs) in target range, anticoagulation-related health care visits, and responses to satisfaction surveys. A significant decrease in anticoagulation control was observed on transition to physician-managed care. Before transition, 76% of all INRs were in target range versus 48% after transition (p<0.0001, chi(2) test). When performing paired analysis, a median 75% of each patient's INRs were therapeutic before transition compared with 36.5% after (p<0.0001, Wilcoxon signed rank test). Thirty-two percent of first INR values measured after transition from the clinic were in target range, and the median time to first follow-up INR was 41 days. The number of INR values above 4.5 and below 1.5 increased significantly after transition from the anticoagulation clinic (p<0.0001 and p=0.01, respectively, chi(2) test). Before transition from the anticoagulation clinic, two anticoagulation-related emergency department visits were reported in one patient. After transition, 13 cases of additional medical care were reported among seven patients; seven of the 13 cases required an office visit with the physician, and six resulted in emergency room evaluation. None of these cases resulted in hospitalization. Patient satisfaction with clinical care provided by the anticoagulation clinic was significantly higher before transition. CONCLUSION: Transition of patients from a pharmacist-managed anticoagulation clinic back to physician-managed anticoagulation care after stabilization of warfarin therapy was associated with a significant decrease in INR control, increased medical care related to anticoagulation, and decreased patient satisfaction.     

Evaluation of a pharmacist-led drive-up anticoagulation clinic during the coronavirus 2019 pandemic

BackgroundThe University of Kentucky HealthCare Anticoagulation Clinic at the Gill Heart and Vascular Institute in Lexington, Kentucky, designed and implemented a drive-up clinic for warfarin management with the goal to minimize person-to-person exposure during the coronavirus disease 2019 (COVID-19) pandemic.ObjectiveThe purpose of this study was to evaluate the effect on warfarin management in a pharmacist-led anticoagulation service when transitioned from an in-person clinic to a drive-up clinic during the COVID-19 pandemic.MethodsThis is a retrospective observational cohort study of 68 patients seen in the University of Kentucky HealthCare Anticoagulation Clinic on warfarin therapy for any indication. Patients were included if they had scheduled visits at least 3 times in the period 6 months before, during, and after the initiation of the drive-up clinic. The primary outcome is the difference in time in therapeutic range (TTR) before and during the drive-up clinic.ResultsThe difference between the mean TTR in period 1 (69.1% ± 23.2%) and period 2 (69.6% ± 19.2%) was not statistically significant (P = 0.882). The mean TTR in period 3 (70.5% ± 20.8%) did not differ in statistical significance from either period 1 (P = 0.688) or period 2 (P = 0.746). Safety outcomes including reported bleeding events and emergency department visits or hospital admissions for bleeding or thrombotic events were consistently low across each period.ConclusionThe results of this study illustrate that a drive-up clinic for warfarin management may be a reasonable alternative approach to providing care for outpatient anticoagulant management and may support nontraditional clinic models for long-term management of anticoagulation and other chronic disease states.     

Impact of clinical pharmacist intervention in anticoagulation clinic in Sudan

Background Many trials have compared anticoagulation management provided by a pharmacist led anticoagulation clinic versus usual physician care showing the role for clinical pharmacist in the management of anticoagulant therapy, and demonstrating excellent outcomes. In Sudan, there is no published research evaluating the role of pharmacist in providing pharmaceutical care for patients taking warfarin. Objective The objective of the study is to assess the role of clinical pharmacist intervention in warfarin patients compared to usual medical care. Setting This study was conducted in Ahmed Gasim cardiac surgery and renal transplant center warfarin clinic. Methods One hundred thirty-five patients were randomly selected from adult patients on warfarin therapy The history of INR records, and adverse effects for the past year, were recorded. Then patients’ warfarin dose adjustments according to INR, was done by the clinical pharmacist for one year. Patients received continuous verbal education and written information about warfarin. Main outcome measure The primary outcome for this study was the INR control, while the secondary outcomes were the bleeding events and hospitalization due to warfarin. Results After the clinical pharmacist intervention there was significant (P < 0.01) improvement in INR control and a significant (P < 0.05) reduction in incidence of bleeding after clinical pharmacist intervention. Hospitalization due to warfarin related complications (bleeding, high INR, low INR) was also significantly (P < 0.001) reduced. Conclusion Clinical pharmacists intervention in warfarin therapy improve INR control, reduce bleeding and hospitalization due to warfarin complications.     

Transition of stable patients from traditional anticoagulation clinic services to telephonic management

Background Outpatient warfarin dosing and monitoring with telephonic anticoagulation management (TAM) could be an effective alternative to other more labor intensive management models. Objectives To evaluate the time in therapeutic range (TTR) and number of extreme INR values (<1.5 or >4.5) of a telephonic system of warfarin management for stable patients who currently utilized traditional anticoagulation management services (AMSs). Method A retrospective, observational cohort with three groups (1) patients transitioned from an office-based anticoagulation clinic to TAM, (2) patients continuously enrolled in office-based AMS, (3) patients continuously managed by usual physician care without specialized anticoagulation services (UPC). Data was collected for six months before and six months after transition. Results All groups demonstrated decreased TTR from baseline to active phase, with the TAM and AMS groups showing similar magnitude of reduction (?10.61 and ?12.66% respectively) but UPC group producing a greater drop (?20.08%). The TAM and AMS groups had similar rates of extreme INR levels; UPC had higher numbers of extreme INRs in three of the four measurements. Conclusion Stable patients transitioned from office-based anticoagulation clinic to a telephonic model of management performed equally as well as those who continued traditional enrollment.