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Al-Qahtani S, Jalal Z, Paudyal V, Mahmood S, Mason J. The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10112315. [PMID: 36421639 PMCID: PMC9691113 DOI: 10.3390/healthcare10112315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/05/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022] Open
Abstract
Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.
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Affiliation(s)
- Saeed Al-Qahtani
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
- School of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia
- Correspondence: ; Tel.: +966-560742224
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sajid Mahmood
- Department of Pharmacy, Quaid-i-Azam University, Islamabad 45320, Pakistan
| | - Julie Mason
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Hawes EM, Lambert E, Reid A, Tong G, Gwynne M. Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am J Health Syst Pharm 2018; 75:901-910. [DOI: 10.2146/ajhp170174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Emily M. Hawes
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Erika Lambert
- UNC Medical Center, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Alfred Reid
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Gretchen Tong
- UNC Family Medicine Center, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Mark Gwynne
- UNC Health Alliance, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
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Hawes EM. Patient Education on Oral Anticoagulation. PHARMACY 2018; 6:E34. [PMID: 29677126 PMCID: PMC6025075 DOI: 10.3390/pharmacy6020034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 01/10/2023] Open
Abstract
Given the potential harm associated with anticoagulant use, patient education is often provided as a standard of care and emphasized across healthcare settings. Effective anticoagulation education involves face-to-face interaction with a trained professional who ensures that the patient understands the risks involved, the precautions that should be taken, and the need for regular monitoring. The teaching should be tailored to each patient, accompanied with written resources and utilize the teach-back method. It can be incorporated in a variety of pharmacy practice settings, including in ambulatory care clinics, hospitals, and community pharmacies.
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Affiliation(s)
- Emily M Hawes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27514, USA.
- University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
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Manzoor BS, Cheng WH, Lee JC, Uppuluri EM, Nutescu EA. Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review. Ann Pharmacother 2017; 51:1122-1137. [PMID: 28735551 DOI: 10.1177/1060028017721241] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE 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). DATA SOURCES 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"). STUDY SELECTION AND DATA EXTRACTION 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. DATA SYNTHESIS 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. CONCLUSIONS 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.
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Affiliation(s)
| | - Wei-Han Cheng
- 2 University of Southern California, Los Angeles, CA, USA
| | - James C Lee
- 1 University of Illinois at Chicago, Chicago, IL, USA
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Entezari-Maleki T, Dousti S, Hamishehkar H, Gholami K. A systematic review on comparing 2 common models for management of warfarin therapy; pharmacist-led service versus usual medical care. J Clin Pharmacol 2015; 56:24-38. [DOI: 10.1002/jcph.576] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/16/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Taher Entezari-Maleki
- Drug Applied Research Center; Tabriz University of Medical Sciences; Tabriz Iran
- Cardiovascular Research Center; Department of Clinical Pharmacy; Tabriz University of Medical Sciences; Tabriz Iran
| | - Samaneh Dousti
- Department of Pediatrics; Children's Hospital; Tabriz University of Medical Sciences; Tabriz Iran
| | - Hadi Hamishehkar
- Drug Applied Research Center; Tabriz University of Medical Sciences; Tabriz Iran
| | - Kheirollah Gholami
- Research Center for Rational Use of Drugs; Department of Clinical Pharmacy; Faculty of Pharmacy; Tehran University of Medical Sciences; Tehran Iran
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Pharmacist Prescribing in Warfarin Therapy: Exploring Clinical Utility in the Hospital Setting. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2008.tb00793.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Harrison J, Shaw JP, Harrison JE. Anticoagulation management by community pharmacists in New Zealand: an evaluation of a collaborative model in primary care. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2014; 23:173-81. [DOI: 10.1111/ijpp.12148] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 06/04/2014] [Indexed: 11/27/2022]
Abstract
Abstract
Objectives
Despite the introduction of new oral anticoagulants, vitamin K antagonists remain the mainstay of the prevention and treatment of thromboembolism. The advent of affordable point-of-care testing presents an opportunity for community pharmacists to provide anticoagulation management services, better utilizing their training, reducing the workload on medical practices and improving accessibility and convenience for patients. This study aimed to determine the effectiveness of anticoagulation management by community pharmacists.
Methods
All patients enrolled in a pilot programme for a community pharmacy anticoagulation management service using point-of-care international normalized ratio testing and computer-assisted dose adjustment were included in a follow-up study, including before–after comparison. Outcomes included time in therapeutic range (TTR), time above and below range, number and proportion of results outside efficacy and safety thresholds, and a comparison of care led by pharmacists and care led by a primary-care general practitioner (GP).
Key findings
A total of 693 patients were enrolled, predominantly males over 65 years of age with atrial fibrillation. The mean TTR was 78.6% (95% CI 49.3% to 100%). A subgroup analysis (n = 221) showed an increase in mean TTR from 61.8% under GP-led care to 78.5% under pharmacist-led care (P < 0.001), reflecting a reduction in the time above and, in particular, below the range. The mean TTR by pharmacy ranged from 71.4% to 84.1%. The median number of tests per month was not statistically different between GP- and pharmacist-led care.
Conclusions
Community-pharmacist-led anticoagulation care utilizing point-of-care testing and computerized decision support is safe and effective, resulting in significant improvements in TTR. Our results support wider adoption of this model of collaborative care.
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Affiliation(s)
- Jeff Harrison
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John P Shaw
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jenny E Harrison
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Shaw J, Harrison J, Harrison J. A community pharmacist-led anticoagulation management service: attitudes towards a new collaborative model of care in New Zealand†. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2014; 22:397-406. [DOI: 10.1111/ijpp.12097] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
To examine attitudes towards a new collaborative pharmacy-based model of care for management of warfarin treatment in the community. As background to the study, the New Zealand health authorities are encouraging greater clinical involvement of community pharmacists.
Methods
Fifteen community pharmacies in New Zealand took part in a community pharmacist-led anticoagulation management service (CPAMS). Participants (patients, general practitioners, practice nurses, pharmacists) were surveyed on their views on accessibility, convenience, confidence in the service, impact on warfarin control, impact on workloads, effect on relationships and whether the service should be further implemented. A small number from each group was interviewed on the same topics.
Key findings
Patients reported improved access, convenience, a preference for capillary testing, and the immediacy of the test result and dose changes. They indicated that they had a better understanding of their health problems. While sample sizes were small, the majority of general practitioners and practice nurses felt there were positive benefits for patients (convenience) and themselves (time saved) and expressed confidence in pharmacists' ability to provide the service. There were some concerns about potential loss of involvement in patient management. Pharmacists reported high levels of satisfaction with better use of their clinical knowledge in direct patient care and that their relationships with both patients and health professionals had improved.
Conclusions
The new model of care was highly valued by patients and supported by primary care practitioners. Wider implementation of CPAMS was strongly supported. Pharmacists and general practitioners involved in CPAMS reported a pre-existing collaborative relationship, and this appears to be important in effective implementation.
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Affiliation(s)
- John Shaw
- Faculty of Medical and Health Sciences, School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Jeff Harrison
- Faculty of Medical and Health Sciences, School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Jenny Harrison
- Faculty of Medical and Health Sciences, School of Pharmacy, University of Auckland, Auckland, New Zealand
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Lalonde L, Martineau J, Blais N, Montigny M, Ginsberg J, Fournier M, Berbiche D, Vanier MC, Blais L, Perreault S, Rodrigues I. Is long-term pharmacist-managed anticoagulation service efficient? A pragmatic randomized controlled trial. Am Heart J 2008; 156:148-54. [PMID: 18585510 DOI: 10.1016/j.ahj.2008.02.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 02/14/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND Some pharmacist-managed anticoagulation services (PMAS) provide initial follow-up to patients on oral anticoagulant, who are transferred to their physician once they are stabilized. This may be as effective as and less expensive than long-term PMAS follow-up. METHODS Once PMAS patients were stabilized and ready for discharge, they were randomized to be transferred to their physician or stay with the PMAS. Quality of international normalized ratio (INR) control, incidence of complications, health-related quality of life, use of health care services, and direct incremental cost of PMAS follow-up were evaluated. RESULTS One hundred thirty-eight physicians and 250 patients participated. Patients were initially followed at the PMAS for a mean of 11.3 weeks and afterwards were followed by their physician (n = 122) or by the PMAS pharmacists (n = 128) for a mean of 14.9 and 14.5 weeks, respectively. Pharmacist-managed anticoagulation services' and physician's patients were within the exact target range 77.3% and 76.7% of the time (95% CI of the difference -4.9% to 6.0%) and within the extended range 93.0% and 91.6% of the time (95% CI -2.1% to 4.7%), respectively. Pharmacist-managed anticoagulation services patients have seen their family physician less often (95% CI -3.1 to -0.1 visit per year). Number of INR tests, incidence of complications, and health-related quality of life were similar in both groups. The incremental cost of PMAS follow-up was estimated at CAN$123.80 per patient year. CONCLUSION Once PMAS patients are well stabilized, maintaining a PMAS follow-up or transferring them to their physician is associated with excellent INR control. However, long-term PMAS follow-up may be more expensive.
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Garcia DA, Witt DM, Hylek E, Wittkowsky AK, Nutescu EA, Jacobson A, Moll S, Merli GJ, Crowther M, Earl L, Becker RC, Oertel L, Jaffer A, Ansell JE. Delivery of Optimized Anticoagulant Therapy: Consensus Statement from the Anticoagulation Forum. Ann Pharmacother 2008; 42:979-88. [PMID: 18559954 DOI: 10.1345/aph.1l098] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To provide recommendations, policies, and procedures pertaining to the provision of optimized anticoagulation therapy designed to achieve desired clinical endpoints while minimizing the risk of anticoagulant-related adverse outcomes (principally bleeding and thrombosis). Study Selection and Data Extraction: Due to this document's scope, the medical literature was searched using a variety of strategies. When possible, recommendations are supported by available evidence; however, because this paper deals with processes and systems of care, high-quality evidence (eg, controlled trials) is unavailable. In these cases, recommendations represent the consensus opinion of all authors who constitute the Board of Directors of The Anticoagulation Forum, an organization dedicated to optimizing anticoagulation care. The Board is composed of physicians, pharmacists, and nurses with demonstrated expertise and significant collective experience in the management of patients receiving anticoagulation therapy. Data Synthesis: Recommendations for delivering optimized anticoagulation therapy were developed collaboratively by the authors and are summarized in 9 key areas: (I) Qualifications of Personnel, (II) Supervision, (III) Care Management and Coordination, (IV) Documentation. (V) Patient Education, (VI) Patient Selection and Assessment, (VII) Laboratory Monitoring, (VIII) Initiation and Stabilization of Warfarin Therapy, and (IX) Maintenance of Therapy. Recommendations are intended to inform the development of care systems containing elements with demonstrated benefit in improvement of anticoagulation therapy outcomes. Recommendations for delivering optimized anticoagulation therapy are intended to apply to all clinicians involved in the care of outpatients receiving anticoagulation therapy, regardless of the structure and setting in which that care is delivered. Conclusions: Anticoagulation therapy, although potentially life-saving, has inherent risks. Whether a patient is managed in a solo practice or a specialized anticoagulation management service, a systematic approach to the key elements outlined herein will reduce the likelihood of adverse events. The need for continued research to validate optimal practices for managing anticoagulation therapy is acknowledged.
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Affiliation(s)
- David A Garcia
- University of New Mexico School of Medicine; Medical Director, Anticoagulation Clinic, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM
| | - Daniel M Witt
- School of Pharmacy, University of Colorado; Manager, Clinical Pharmacy Services, Kaiser Permanente Colorado, Denver, CO
| | - Elaine Hylek
- School of Medicine, Boston University; Director, Anticoagulation Clinic, Boston Medical Center, Boston, MA
| | - Ann K Wittkowsky
- Clinical Professor, School of Pharmacy, University of Washington; Director, Anticoagulation Services, University of Washington Medical Center, Seattle, WA
| | - Edith A Nutescu
- Clinical Associate Professor of Pharmacy Practice; Director, Antithrombosis Center, College of Pharmacy & Medical Center, The University of Illinois at Chicago, Chicago, IL
| | - Alan Jacobson
- Anticoagulation Services; Associate Chief of Staff for Research, Loma Linda Veterans Affairs Medical Center, Loma Linda, CA
| | - Stephan Moll
- School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Geno J Merli
- Medicine, Jefferson Medical College, Thomas Jefferson University; Senior Vice President and Chief Medical Officer, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Mark Crowther
- Academic Division Director, Hematology and Thromboembolism, McMaster University; Director of Laboratory Hematology, Hamilton Regional Laboratory Medicine Program; Head of Service, Hematology, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Laura Earl
- Practicing Nurse, University of New Mexico, Albuquerque
| | - Richard C Becker
- Medicine, School of Medicine, Duke University; Director, Duke Cardiovascular Thrombosis Center, Duke Clinical Research Institute, Durham, NC
| | - Lynn Oertel
- Clinical Nurse Specialist, Anticoagulation Management Services, Massachusetts General Hospital, Boston, MA
| | - Amir Jaffer
- Division Chief of Hospital Medicine, University of Miami, Miami, FL
| | - Jack E Ansell
- Department of Medicine, Lenox Hill Hospital, New York, NY
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Newman DH, Zhitomirsky I. The prevalence of nontherapeutic and dangerous international normalized ratios among patients receiving warfarin in the emergency department. Ann Emerg Med 2006; 48:182-9, 189.e1. [PMID: 16953531 DOI: 10.1016/j.annemergmed.2005.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We determine the prevalence of nontherapeutic and coagulopathic international normalized ratios (INRs) among patients receiving warfarin and presenting to an emergency department (ED). As a secondary goal, we aim to determine whether a simple decision aid composed of physical examination and historical features could be predictive of INR greater than 5. METHODS This was a prospective, observational study at 2 associated urban academic centers from February 2003 through May 2004, using a convenience sample of patients identified by direct questioning and contemporaneous medical record review in the ED as receiving long-term warfarin therapy. Inclusion criteria were warfarin therapy and self-reported compliance. Patients were enrolled by trained researchers. The primary outcome measure was the percentage of patients within appropriate therapeutic range for their condition according to accepted national guidelines. Descriptive statistics were used, and multivariate regression analysis was performed to identify associations. RESULTS One thousand nineteen patients were enrolled. INR values were obtained in 77% (782/1019) of patients. Of these patients, 72% (95% confidence interval 67% to 76%) were outside the desired range. Values were less than 2 in 43% of patients and greater than 3 in 29% of patients. INR greater than 5 was present in 11% (86/782) of patients, and 40% (34/86) of these patients exhibited gross bleeding. Emergency therapy was administered in 12% (96/782) of patients: fresh frozen plasma in 7% of patients, heparin in 5% of patients. Intracranial hemorrhage was found in 12 patients, 5 with INR greater than 3. Ischemic stroke or venous thromboembolism occurred in 51 patients known to be receiving warfarin specifically for prevention of the event that occurred. Of these patients, 49% (25/51) had INR less than 2. Regression analysis indicated no sensitive or specific constellation of features, though 2 factors were associated with INR greater than 5: gross hemorrhage (P=.006) and increasing duration of therapy (P=.047). CONCLUSION The prevalence of undesirable INR in the ED is higher than in warfarin populations previously studied, and a significant number of nontherapeutic levels were associated with thromboembolism, stroke, or hemorrhage. Given the prevalence and established danger of subtherapeutic and supratherapeutic levels, a low threshold should be maintained for testing and addressing INR levels in patients receiving warfarin in the ED.
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Affiliation(s)
- David H Newman
- St. Luke's-Roosevelt Hospital Center, New York, NY, USA.
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Abstract
PURPOSE The implementation of supplementary prescribing by pharmacists within primary care trusts (PCTs) and secondary care trusts (SCTs) in England was studied. METHODS A survey was developed and sent to pharmacists in PCTs and SCTs in England who would oversee the implementation of supplementary prescribing by pharmacists. RESULTS The response rate was 68% for both surveys. The majority of SCTs and PCTs intended to implement supplementary prescribing by pharmacists by the end of 2005 (57% and 56%, respectively). The majority of SCT respondents did not believe that it would be more difficult to recruit designated medical practitioners to supervise supplementary prescribing training for pharmacists as opposed to nurses (67%, n = 43), whereas the largest group of PCT pharmacists believed it would be (47%, n = 86). Within secondary care, the clinical areas in which pharmacists were intending to work as supplementary prescribers were those where they already had established roles. Within primary care, the main clinical areas for pharmacists were influenced by those areas in the new General Medical Services contract Quality and Outcomes Framework for general practitioners. CONCLUSION A survey investigating the implementation of supplementary prescribing by pharmacists in England found that there were significantly more barriers to its establishment within primary care than secondary care settings. Within primary care, supplementary prescribing is being implemented to develop new services. Within secondary care, the supplementary prescribing model is more often used to legitimize services already being provided.
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Affiliation(s)
- Rachel J Hobson
- Department of Pharmacy and Pharmacology, University of Bath and Swindon and Marlborough NHS Trust, England, United Kingdom.
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Gérvas J, Pérez Fernández M. ¿Cuál es el límite en la prestación de servicios cercanos al paciente? El límite lo marca la tensión entre el «síndrome del barquero» y «el síndrome del gato». Med Clin (Barc) 2005; 124:778-81. [PMID: 15927105 DOI: 10.1157/13075848] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Juan Gérvas
- Médico general, Equipo CESCA, Madrid, España.
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Garcia DA, Ageno W, Libby EN, Bibb J, Douketis J, Crowther MA. Perioperative Anticoagulation for Patients with Mechanical Heart Valves: A Survey of Current Practice. J Thromb Thrombolysis 2004; 18:199-203. [PMID: 15815882 DOI: 10.1007/s11239-005-0346-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with mechanical heart valves (MHV) require temporary interruption of warfarin when undergoing invasive procedures. Current guidelines addressing this subject are discordant because there is no high quality evidence to support any single management strategy. We tested the hypothesis that there is significant practice variation amongst clinicians caring for patients with MHV who require temporary cessation of their warfarin therapy. METHODS A survey describing 4 hypothetical patients with mechanical heart valves was distributed to all clinicians attending an anticoagulation specialty meeting. For each scenario, the attendee was given several choices for preoperative and postoperative anticoagulation management. Information about each respondent's profession, specialty and the frequency with which they make perioperative anticoagulation recommendations was also collected. RESULTS Three hundred twenty-four of 650 surveys were returned. In each of the case scenarios, a majority of respondents selected subcutaneous low molecular weight heparin (LMWH) or subcutaneous unfractionated heparin (UH) as the preferred pre- and postoperative anticoagulant. Significant variation in practice was noted: for none of the questions was a single strategy selected by greater than 80% of respondents. CONCLUSION Expert clinicians differ in their perioperative management strategies for patients with MHV who require interruption of warfarin. Although subcutaneous LMWH/UH was the treatment of choice in all scenarios, the lack of consensus found in our survey highlights the need for randomized controlled clinical trials of peri-procedural anticoagulant therapy. This survey of anticoagulation experts reveals that there is significant practice variation in scenarios where temporary interruption of warfarin is necessary in patients with mechanical heart valves. Despite discordant guidelines and a lack of high-quality data to support any strategy, a majority of the respondents surveyed would use low molecular weight heparin (or subcutaneous unfractionated heparin) to anticoagulate patients with mechanical heart valves during the peri-operative period.
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Affiliation(s)
- David A Garcia
- Internal Medicine, University of New Mexico, Albuquerque, NM 87131, USA.
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Holm T, Lassen JF, Husted SE, Christensen P, Heickendorff L. A randomized controlled trial of shared care versus routine care for patients receiving oral anticoagulant therapy. J Intern Med 2002; 252:322-31. [PMID: 12366605 DOI: 10.1046/j.1365-2796.2002.01039.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the effect of a shared care programme (SCP), defined as a scheme based on shared responsibility, enhanced information exchange, continues medical education and explicit clinical guidelines, between general practitioners (GPs) and a hospital outpatient clinic (HOC), on oral anticoagulant therapy (OAT). DESIGN The study was a 2-year prospective, randomized, controlled trial, preceded by a 1-year period of observation. SETTING The HOC, GPs, and OAT patients in the admission area of Aarhus University Hospital, Aarhus County, Denmark, covering 310 300 inhabitants. SUBJECTS A total of 207 GPs, including their enlisted patients on OAT, were invited, and 61.4% accepted participation. They were randomized into an intervention group [group-INT: 64 GPs and 453 patients (170 patients on OAT throughout the study period, i.e. full follow-up)], and a control group [group-CON: 63 GPs and 422 patients (173 with full follow-up)]. The remaining 80 GPs served as a nonresponder group (group-NON) of 485 patients (184 with full follow-up). MAIN OUTCOME MEASURE Therapeutic control of OAT in terms of time spent by the patients within the therapeutic interval (TI) of an international normalized ratio (INR) between 2.0 and 3.5. RESULTS The groups did not differ significantly with regard to age, sex, OAT indication, anticoagulant drug used, or the therapeutic control at baseline. In a comparison based on intention-to-treat principles, the therapeutic control increased statistical significance amongst patients with full follow-up in group-INT compared with group-CON (median time within TI: group INT = 86.6% vs. 80.5%, P = 0.007). CONCLUSION An SCP of anticoagulant management is effective in reducing patient time outside the therapeutic INR interval in OAT patients randomly assigned to an SCP, as compared with a control group.
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Affiliation(s)
- T Holm
- Department of Internal Medicine and Cardiology A, Unit of Health Technology Assessment, Aarhus University Hospital, Olof Palmes Allé 17, 1, DK-8200 Aarhus N, Denmark.
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Holm T, Deutch S, Lassen JF, Jastrup B, Husted SE, Heickendorff L. Prospective evaluation of the quality of oral anticoagulation management in an outpatient clinic and in general practices. Thromb Res 2002; 105:103-8. [PMID: 11958799 DOI: 10.1016/s0049-3848(01)00401-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the quality of oral anticoagulant therapy (QOAT), before and after referral of patients on oral anticoagulant therapy (OAT) from a hospital outpatient clinic (HOC) to general practitioners (GPs). DESIGN Prospective observational study. Patients were identified by using the Laboratory Information System (LIS), containing all prescribed International Normalised Ratio of Prothrombin Time (INR) tests, from the HOC and GPs in the hospital submission area. SETTING The HOC in a rural hospital, Aarhus County, Denmark (55,000 inhabitants), and GPs in the submission area. SUBJECTS 124 OAT patients (59.7% males. Median age 70.0: 25-75 percentile: 62.0-76.0). MAIN OUTCOME MEASURE The QOAT in terms of time spent within therapeutic INR interval (TI). The QOAT was compared 8 months before with 8 months after altering the monitoring organization. For patients monitored less than 8 months before the alteration, the QOAT was compared to a corresponding time period after the alteration. RESULTS We identified 124 OAT patients, and found a significant increase in the QOAT from 65.0% before to 69.1% after referral of the patients to the GPs (P<.0001). In 75 patients with full follow-up, the QOAT increased from 67.5% before to 69.7% after the alteration (P<.0001). CONCLUSION The results indicate that the QOAT in this geographical area is adequate, and that the quality performed by the GPs was at least as good as in the HOC. In order to document and increase the QOAT, continuous quality surveillance using the LIS has been initiated.
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Affiliation(s)
- Tomas Holm
- Department of Medicine and Cardiology A, Aarhus Amtssygehus, Aarhus University Hospital, Tage Hansensgade 2, DK-8000 Aarhus C, Denmark.
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