Clinical, economic, and humanistic impact of a multidisciplinary medication review with follow-up for anticoagulated patients treated with vitamin K antagonists in primary care: A cluster randomised controlled trial

BACKGROUND

Interdisciplinary collaboration between general practitioner, nurses and pharmacists can favour the control of patients treated with vitamin K antagonists (VKA), increasing their safety and effectiveness. The aim of the study was to evaluate the impact of pharmaceutical interventions on patients treated with VKA within the framework of a Pharmacotherapeutic Follow-up service on clinical, economic and humanistic outcomes.

METHODS

Controlled and randomized study in patients from two health areas of Zaragoza in treatment with VKA with Time in Therapeutic Range (TTR) according to the Rosendaal method less than 70% in the last 6 months. Patients were recruited at the pharmacy and assigned to two groups: control and intervention. A Pharmacotherapeutic Follow-up Program was established for the intervention group for 6 months. The outcome variables were INR stability, pharmacological adherence, vitamin K intake, knowledge about the use of acenocoumarol, quality of life, satisfaction with treatment, associated costs and avoided costs. A descriptive analysis was performed, and the Students' T test or Mann-Whitney U test was used for the association between quantitative variables and Chi-square or Fisher's test for qualitative variables.

RESULTS

A total of 123 patients were included, 65 in the intervention group (IG) and 58 in the control group (CG). A total of 108 interventions were conducted (1.7 interventions/patient) and the most common were those related to the proper taking of medications (41.0%). In IG, TTR (p = 0.019), adherence to treatment (p = 0.038) and knowledge about acenocoumarol (p = 0.031) improved, compared to CG. A higher proportion of patients in IG achieved a TTR>65% (p = 0.024). In addition, patients whose interventions were accepted by the physician (p = 0.027) and those who received vitamin K optimization interventions (p = 0.003) achieved TTR>65% in greater proportion.

CONCLUSIONS

Community pharmacist medication review, in collaboration with general practitioners improve knowledge and adherence of patients treated with oral anti-vitamin K agents and enhances the achievement of their therapeutic INR ranges. Investment needed to achieve this clinical impact is low and patient satisfaction is high.

TRIAL REGISTRATION

This study has been registered with Clinical Trials.gov dated 25/05/2017: NCT03154489.

The Pharmacist's role in dermatology: Patient medication adherence

Medication non-adherence is currently estimated to have caused at least 100 000 preventable deaths and over $100 billion in preventable medical costs. Adherence is particularly poor in dermatological conditions, with more than 50% of patients discontinuing topical treatments within the first year. Pharmacists are among the most accessible health-care professionals with the potential to greatly impact medication non-adherence through patient education, medication therapy management, and improved access to care. This review aimed to determine how pharmacists have improved medication adherence in dermatology and discuss strategies for further involvement. An extensive medical literature search using the PubMed database was conducted to evaluate clinical studies, published in the last 20 years, that have evaluated the pharmacist's role and impact on adherence of to dermatological products. PubMed search terms include: "pharmacists' role in dermatologic medication adherence", "pharmacist-led interventions in dermatology", "pharmacist medication adherence dermatology" and "pharmacist intervention dermatology". A total of 18 relevant studies were identified. Pharmacists improved dermatological medication adherence by increasing access to medications, providing medication counseling programs, and performing treatment monitoring services. However, corticophobia may contribute to pharmacists' hesitancy in making corticosteroid over-the-counter recommendations. Pharmacists are accessible health-care providers with the potential to improve dermatological medication adherence. Future advanced training in dermatology medications may refine pharmacists' knowledge of dermatological products.

Medical Treatment for Rheumatic Heart Disease: A Narrative Review

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in high-income countries; however, in Aotearoa New Zealand ARF and RHD disproportionately affect Indigenous Māori and Pacific Peoples. This narrative review explores the evidence regarding non-surgical management of patients with clinically significant valve disease or heart failure due to RHD.

METHODS

Medline, EMBASE and Scopus databases were searched, and additional publications were identified through cross-referencing. Included were 28 publications from 1980 onwards.

RESULTS

Of the available interventions, improved anticoagulation management and a national RHD register could improve RHD outcomes in New Zealand. Where community pharmacy anticoagulant management services (CPAMS) are available good anticoagulation control can be achieved with a time in the therapeutic range (TTR) of more than 70%, which is above the internationally recommended level of 60%. The use of pharmacists in anticoagulation control is cost-effective, acceptable to patients, pharmacists, and primary care practitioners. There is a lack of local data available to fully assess other interventions; including optimal therapy for heart failure, equitable access to specialist RHD care, prevention, and management of endocarditis.

CONCLUSION

As RHD continues to disproportionately affect Indigenous and minority groups, pro-equity tertiary prevention interventions should be fully evaluated to ensure they are reducing disease burden and improving outcomes in patients with RHD.

Cost saving analysis of specialized, eHealth-based management of patients receiving oral anticoagulation therapy: Results from the thrombEVAL study

To evaluate the cost-saving of a specialized, eHealth-based management service (CS) in comparison to regular medical care (RMC) for the management of patients receiving oral anticoagulation (OAC) therapy. Costs of hospitalization were derived via diagnosis-related groups which comprise diagnoses (ICD-10) and operation and procedure classification system (OPS), which resulted in OAC-related (i.e. bleeding/ thromboembolic events) and non-OAC-related costs for both cohorts. Cost for anticoagulation management comprised INR-testing, personnel, and technical support. In total, 705 patients were managed by CS and 1490 patients received RMC. The number of hospital stays was significantly lower in the CS cohort compared to RMC (CS: 23.4/100 py; RMC: 68.7/100 py); with the most pronounced difference in OAC-related admissions (CS: 2.8/100 py; RMC: 13.3/100 py). Total costs for anticoagulation management amounted to 101 EUR/py in RMC and 311 EUR/py in CS, whereas hospitalization costs were 3261 [IQR 2857-3689] EUR/py in RMC and 683 [504-874] EUR/py in CS. This resulted in an overall cost saving 2368 EUR/py favoring the CS. The lower frequency of adverse events in anticoagulated patients managed by the telemedicine-based CS compared to RMC translated into a substantial cost-saving, despite higher costs for the specialized management of patients.Trial registration: ClinicalTrials.gov, unique identifier NCT01809015, March 8, 2013.

Effectiveness of Telepharmacy Versus Face-to-Face Anticoagulation Services in the Ambulatory Care Setting: A Systematic Review and Meta-analysis

BACKGROUND

Effectiveness of anticoagulation services managed via telepharmacy (TP) has not been clearly demonstrated.

OBJECTIVE

This systematic review and meta-analysis compares the effectiveness of TP anticoagulation services to face-to-face (FTF) anticoagulation services in the ambulatory care setting.

METHODS

A literature search for studies assessing the effectiveness of TP services was conducted using PubMed, EMBASE, and Cochrane Central databases, from inception through November 18, 2020. Studies that compared TP with FTF anticoagulation services in the ambulatory care setting were included. Outcomes of interest included thromboembolic events, major bleeding, minor bleeding, any bleeding, warfarin international normalized ratio (INR) time in therapeutic range (TTR), frequency of extreme INR, anticoagulation-related emergency department visits, anticoagulation-related hospitalization, any hospitalization, and mortality. Relative risk (RR) and weighted mean difference were calculated using the DerSimonian and Laird random-effects model.

RESULTS

Overall, 11 studies involving 8395 patients were included in the systematic review, and 9 studies were included in the pooled meta-analysis. Compared with FTF service, TP was associated with a lower risk of any bleeding and any hospitalization, with RRs of 0.65 (95% CI = 0.47 to 0.90; P = 0.01) and 0.59 (95% CI = 0.39 to 0.87; P = 0.01), respectively. There was no statistically significant difference in TTR or the risk of extreme supratherapeutic INR, major bleeding, minor bleeding, or thromboembolic events between the 2 groups.

CONCLUSIONS

TP appears to be at least as effective as FTF anticoagulation services. Findings from this study support the utilization of TP practice models in ambulatory care anticoagulation management.

Evaluation of the Long-Term Impact on Quality After the End of Pharmacist-Driven Warfarin Therapy Management in Patients With Poor Quality of Anticoagulation Therapy

Background

Warfarin is the most common oral anticoagulant drug, especially in low-income and emerging countries, because of the high cost of direct oral anticoagulant (DOACs), or when warfarin is the only proven therapy (mechanical prosthetic valve and kidney dysfunction). The quality of warfarin therapy is directly associated with dose management. Evidence shows that pharmaceutical care achieves a better quality of therapy with warfarin. However, there are no studies showing this intervention in a specific patient group with poor quality of anticoagulation in a long period after the end of the follow-up by a pharmacist. Thus, the aim of this study was to evaluate whether the quality of warfarin therapy driven by a pharmacist remains stable in the long term after the end of follow up with a pharmacist, in AF patients with poor quality of anticoagulation.

Methods

This is a prospective study, which evaluated about 2,620 patients and selected 262 patients with AF and poor quality of anticoagulation therapy with warfarin (TTR<50% - based on the last three values of international normalized ratio). Pharmacist-driven therapy management was performed up to 12 weeks. Data from patients were evaluated 1 year after the end of the follow-up with pharmacist.

Results

Comparison between mean TTR after 12 weeks of pharmaceutical care (54.1%) and mean TTR one year after the end of the pharmaceutical care (56.5%; p=0.081) did not achieve statistical difference, demonstrating that the increment of quality due to intervention of 12 weeks was maintained for 1 year after intervention.

Conclusion

The long-term impact of pharmaceutical care was beneficial for patients with AF and poor quality of warfarin anticoagulation. This design might be an important strategy to treat a subgroup of patients without proven effectiveness of warfarin.

Comparative effects of telemedicine and face-to-face warfarin management: A systematic review and network meta-analysis

OBJECTIVE

To determine the comparative effects of different types of telemedicine on anticoagulation control and adverse outcomes in patients taking warfarin.

DATA SOURCES

A systematic search was conducted in PubMed, the Cochrane library, EMBASE, CINAHL, OpenGrey, and DART-Europe from inception to September 2019.

STUDY SELECTION

Randomized controlled trials, quasi-experimental and cohort studies were included if they evaluated the effect of telemedicine in patients using warfarin for 3 months or more.

METHODS

Two reviewers extracted and assessed the quality of studies by means of the Cochrane Effective Practice and Organization of Care Group. Network meta-analyses were performed using a random-effects model. Surface under the cumulative ranking curve (SUCRA) methods were used to rank different telemedicine types.

RESULTS

Of the 14,673 articles retrieved, 12 studies involving 11,478 patients met the inclusion criteria. The 5 types of telemedicine categorized were 1) laboratory draw with individual telephonic follow-up by health care (HC) providers (Lab/Tel/HC); 2) laboratory draw with individual telephonic follow-up with periodic, routine routine face-to-face (F2F) visit (Lab/Tel+F2F/HC); 3) laboratory draw with individual and group follow-up via online access (Lab/Online/HC); 4) patient self-test (PST) with telephonic or Web-based follow-up by automated management system (PST/Tel-Online/Auto); and 5) PST with telephonic follow-up by HC provider (PST/Tel/HC). PST/Tel-Online/Auto appears to be superior to F2F for TTR (mean difference 8.78%; 95% CI 0.06%-17.50%) and Lab/Online/HC for in-range INR (odds ratio 2.59; 95% CI 1.04-6.46). The SUCRAs suggested that PST/Tel-Online/Auto was preferred for both TTR and INR, at 84.2% and 93.9%, respectively, whereas Lab/Tel/HC was preferred to prevent major bleeding (74.1%) or thromboembolic event (70.7%).

CONCLUSION

According to the current evidence of uncertain quality, the best effects on anticoagulation control and adverse outcomes were achieved from different types of telemedicine. Variations in the effects of telemedicine on diverse outcomes should be considered before implementing telemedicine interventions in patients taking warfarin.

Clinical Outcomes of Telephone Service for Patients on Warfarin: A Systematic Review and Meta-Analysis

Objective: To evaluate clinical outcomes of telephone-based service for patients on warfarin. Methods: Five bibliographic databases and gray literature were searched for articles that reported the effects of telephone interventions provided to patients using warfarin compared with those receiving usual clinic-based care. Mean difference (MD) and relative risk (RR) were used to calculate the effects of telephone intervention on time in therapeutic range (TTR) and visit in range (VIR), respectively. Adverse events (AEs) were pooled and reported as incidence rate ratios. Results: A total of 1,840 articles were examined. Eight articles involving 8,087 subjects were included in the quantitative synthesis. The pooled estimates from seven studies showed no difference on TTR between the telephone service group and the usual care group (MD 2.30; 95% confidence interval [CI] -3.56 to 8.16). In addition, VIR in the telephone service group was not different from the usual care group (RR 1.22, 95% CI 0.87-1.71). Moreover, patients in telephone service groups appeared to have a lower incidence of AEs compared with usual care groups. Discussion: Telephone-based service could be considered as an alternative anticoagulant management. However, owing to a lack of evidence from well-designed studies, further high-quality randomized control trials are warranted.

Medication therapy disease management: Geisinger's approach to population health management

PURPOSE

Pharmacists' involvement in a population health initiative focused on chronic disease management is described.

SUMMARY

Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients.

CONCLUSION

The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.

Interdisciplinary Care Team with Pharmacist in a Community-based HIV Clinic

BACKGROUND

Human immunodeficiency virus (HIV) infection presents a significant burden, especially in the Washington, DC area. Literature is limited in describing the role of pharmacists in the outpatient clinic setting to provide patient-centered pharmaceutical care for patients with HIV.

OBJECTIVE

Our study aims to describe an interdisciplinary HIV care model including a clinical pharmacist at a community-based transcultural clinic in the Washington, DC area, and to describe the role of the pharmacist as indicated by an association between non-adherence to antiretroviral therapy (ART) and an ART regimen change.

METHODS

Using the electronic health record at the clinic from May 2011 through July 2013, 53 patients were identified who were referred to the clinical pharmacist.

RESULTS

The average age of the patients with HIV was 46.57 years in the clinic. About 28% of patients had documented non-adherence to ART and 30% of patients had one or more ART regimen changes during the study period. Medication non-adherence was a significant predictor of ART regimen change (OR_adj 8.44; 95% CI 1.91-37.29). Substance use was a strong predictor of ART regimen change (OR_unadj 3.47; 95% CI 1.02-11.81), but the relationship disappeared in the multivariate analysis.

CONCLUSIONS

A strong association between pharmacist's evaluation of non-adherence to ART and a regimen change was demonstrated and the role of the pharmacist as the interdisciplinary team member was described. A follow-up study should be made to assess the services provided by the pharmacist on clinical, economic, and humanistic outcomes in the community-based clinical setting.

Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review

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.

Improving Warfarin Management Within the Medical Home: A Health-System Approach

BACKGROUND

Anticoagulation clinics have been considered the optimal strategy for warfarin management with demonstrated improved patient outcomes through increased time in therapeutic international normalized ratio (INR) range, decreased critical INR values, and decreased anticoagulation-related adverse events. However, not all health systems are able to support a specialized anticoagulation clinic or may see patient volume exceed available anticoagulation clinic resources. The purpose of this study was to utilize an anticoagulation clinic model to standardize warfarin management in a primary care clinic setting.

METHODS

A warfarin management program was developed that included standardized patient assessment, protocolized warfarin-dosing algorithm, and electronic documentation and reporting tools. Primary care clinics were targeted for training and implementation of this program.

RESULTS

The warfarin management program was applied to over 2000 patients and implemented at 39 clinic sites. A total of 160 nurses and 15 pharmacists were trained on the program. Documentation of warfarin dose and date of the next INR increased from 70% to 90% (P <.0001), documentation occurring within 24 hours of the INR result increased from 75% to 87% (P <.0001), and monitoring the INR at least every 4 weeks increased from 71% to 83% (P <.0001) per patient encounter. Time in therapeutic INR range improved from 65% to 75%.

CONCLUSION

Incorporating a standardized approach to warfarin management in the primary care setting significantly improves warfarin-related documentation and time in therapeutic INR range.

Impact of Warfarin Persistence on Health-Care Utilization and Costs Among Patients With Atrial Fibrillation Managed in Anticoagulation Clinics in the United States

Warfarin is a recommended therapy to reduce the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). The objectives of this study were to identify potential factors associated with warfarin persistence and evaluate the impact of warfarin persistence on health-care resource utilization and costs among patients with NVAF in the United States. Patients (≥18 years) with ≥1 inpatient or ≥2 outpatient diagnoses of AF without valvular disease were identified from an electronic medical record database (January 1, 2004, to January 31, 2015). The patients with NVAF were grouped into 2 cohorts-persistent with warfarin therapy and not persistent (warfarin discontinuation in <365 days). A multivariable regression was used to identify potential predictors of warfarin persistence. Health-care costs were evaluated during a 12-month follow-up period for study cohorts. Among the study population, 52%, (n = 4086) were persistent with warfarin therapy and 48% (n = 3722) were not. Patients with NVAF with higher Charlson comorbidity index and CHADS₂ scores versus those with scores of 0 were more likely to demonstrate persistence with warfarin therapy. After adjusting for patient characteristics, patients with NVAF persistent with warfarin therapy versus those who were not were 30% less likely to be hospitalized during the follow-up period ( P < .001). Additionally, total all-cause health-care costs (US $2183, P < .001) and stroke-related costs (US $788, P < .001) were significantly lower among patients persistent with warfarin therapy versus those who were not. Patients with NVAF who have greater comorbidity and stroke risk are more likely to be persistent with warfarin therapy. Patients with NVAF who are persistent with warfarin therapy versus those who are not have lower all-cause and stroke-related health-care costs.

Role of the pharmacist in reducing healthcare costs: current insights

Global healthcare expenditure is escalating at an unsustainable rate. Money spent on medicines and managing medication-related problems continues to grow. The high prevalence of medication errors and inappropriate prescribing is a major issue within healthcare systems, and can often contribute to adverse drug events, many of which are preventable. As a result, there is a huge opportunity for pharmacists to have a significant impact on reducing healthcare costs, as they have the expertise to detect, resolve, and prevent medication errors and medication-related problems. The development of clinical pharmacy practice in recent decades has resulted in an increased number of pharmacists working in clinically advanced roles worldwide. Pharmacist-provided services and clinical interventions have been shown to reduce the risk of potential adverse drug events and improve patient outcomes, and the majority of published studies show that these pharmacist activities are cost-effective or have a good cost:benefit ratio. This review demonstrates that pharmacists can contribute to substantial healthcare savings across a variety of settings. However, there is a paucity of evidence in the literature highlighting the specific aspects of pharmacists' work which are the most effective and cost-effective. Future high-quality economic evaluations with robust methodologies and study design are required to investigate what pharmacist services have significant clinical benefits to patients and substantiate the greatest cost savings for healthcare budgets.

Advantages of a Warfarin Protocol for Long-term Care Pharmacists: a Retrospective Cohort Study

Background

Warfarin is an anticoagulant prescribed to 12% of long-term care residents to reduce the risk of thrombo-embolism. This study used indicators to compare warfarin management by pharmacists to usual care.

Methods

This was a retrospective cohort study comparing a pharmacist-managed warfarin protocol with usual care of qualified warfarin recipients at long-term care facilities (two protocol, one control) in Calgary, Alberta. We compared the proportion of international normalized ratio (INR) tests in the range 2.0 to 3.0, time in range, number of tests, and frequency of bleeding at protocol and control sites. Our primary outcome, time in INR therapeutic range, is an indicator for assuring care quality. A cross-sectional survey at these sites compared health professionals’ perceptions of workload and effectiveness of warfarin management.

Results

Of the 197 residents’ charts reviewed in the study period, those on protocol had 45.0 INR tests while those on usual care had 52.7 tests (p = .034, 95% CI for the difference: 0.6 to 14.6 INR tests). No significant difference was found for time in therapeutic range, number of tests in range, or major bleeding events. Of 178 health professionals surveyed, those from protocol facilities were more satisfied with warfarin management (p = .013). Workload and safety were perceived similarly at all sites.

Interpretation

Our results suggest that a pharmacist-managed warfarin protocol is as effective as usual care and has advantages pertaining to work satisfaction, knowledge of drug interactions, consistent documentation, and fewer INR tests. Further research on teamwork and coagulation management in long-term care facilities is recommended.

Warfarin time in therapeutic range and its impact on healthcare resource utilization and costs among patients with nonvalvular atrial fibrillation

BACKGROUND

Warfarin is efficacious for reducing stroke risk among patients with nonvalvular atrial fibrillation (NVAF). However, the efficacy and safety of warfarin are influenced by its time in therapeutic range (TTR).

OBJECTIVE

To assess differences in healthcare resource utilization and costs among NVAF patients with low (<60%) and high (≥60%) warfarin TTRs in an integrated delivery network (IDN) setting.

METHODS

Patients with NVAF were identified from an electronic medical record database. Patients were required to have ≥6 international normalized prothrombin time ratio (INR) tests. NVAF patients were grouped into two cohorts: those with warfarin TTR <60% (low TTR) and those with warfarin TTR ≥60% (high TTR). Healthcare resource utilization and costs were evaluated during a 12 month follow-up period. Multivariable regressions were used to assess the impact of different warfarin TTRs on healthcare costs.

RESULTS

Among the study population, greater than half (54%, n = 1595) had a low TTR, and 46% (n = 1356) had a high TTR. Total all-cause healthcare resource utilization was higher among patients in the low TTR cohort vs. the high TTR cohort (number of encounters: 70.2 vs. 56.1, p < 0.001). After adjusting for patient characteristics, total all-cause healthcare costs and stroke-related healthcare costs were $2398 (p < 0.001) and $687 (p = 0.02) higher, respectively, for patients in the low TTR cohort vs. the high TTR cohort.

LIMITATIONS

In this retrospective study, we were only able to evaluate the association and not the causality between healthcare resource utilization and costs with the different warfarin TTRs.

CONCLUSION

Many warfarin-treated NVAF patients have a low warfarin TTR. NVAF patients with low vs. patients with high warfarin TTR used healthcare resources to a greater extent, which was reflected in higher healthcare costs.

Pharmacist-managed international normalized ratio patient self-testing is associated with increased time in therapeutic range in patients with left ventricular assist devices at an academic medical center

Patients with left ventricular assist devices (LVADs) are at increased risk of bleeding and thrombotic complications making warfarin therapy particularly challenging. Patient self-testing (PST) using point-of-care international normalized ratio (INR) devices has shown favorable outcomes in other populations, but the use of PST in LVAD patients has not been well described. The purpose of this study was to evaluate the effectiveness of pharmacist-managed INR PST versus usual care (UC) in patients with LVADs at a single center. We performed a retrospective cohort study of adult patients (in a 1:4 ratio PST versus UC) implanted with an LVAD (HeartMate II or HVAD) treated with warfarin from January 1, 2007, to January 31, 2013. We reviewed all INRs and bleeding/thrombotic events in LVAD patients whose anticoagulation was managed by clinical pharmacists via INR PST versus UC and calculated a percent time in therapeutic range (%TTR) by Rosendaal method. Fifty-five patients were studied. Demographic data were generally similar between the cohorts. Mean %TTR was higher in the PST cohort versus UC (44.4% vs. 30.6%, p = 0.026). There was no difference in the rate per patient-year of bleeding (0.23 vs. 0.33, p = 0.55) or thrombotic events (0.12 vs. 0.13, p = 0.88). Pharmacist-managed INR PST is associated with an increased %TTR in patients with LVADs.

Utilization of collaborative practice agreements between physicians and pharmacists as a mechanism to increase capacity to care for hematopoietic stem cell transplant recipients

Survival after hematopoietic stem cell transplantation (HSCT) has improved and the number of allogeneic HSCTs performed annually in the United States is expected to reach 10,000 by 2015. The National Marrow Donor Program created the System Capacity Initiative to formulate mechanisms to care for the growing number of HSCT recipients. One proposed method to increase capacity is utilization of pharmacists to manage drug therapy via collaborative practice agreements (CPAs). Pharmacists have managed drug therapy in oncology patients with CPAs for decades; however, there are limited HSCT centers that employ this practice. Engaging in collaborative practice and billing agreements with credentialed pharmacists to manage therapeutic drug monitoring, chronic medical conditions, and supportive care in HSCT recipients may be cost-effective and enable physicians to spend more time on new or more complex patients. The goal of this paper is to provide a framework for implementation of a CPA and address how it may improve HSCT program capacity.

Warfarin for Venous Thromboembolism Prophylaxis After Elective Hip or Knee Arthroplasty: Exploring the Evidence, Guidelines, and Challenges Remaining

BACKGROUND:

Guidelines for the prevention of venous thromboembolism (VTE) after elective total hip or knee arthroplasty (THA/TKA) have been developed separately by the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Differences exist in approaches to preventing postoperative VTE through prophylaxis.

OBJECTIVE:

To compare trials using vitamin K antagonists (VKAs) and differences in guidelines to determine the benefits and drawbacks of warfarin for VTE prophylaxis following THA/TKA.

DATA SOURCES:

Guidelines from the AAOS published in 2009 and revised in 2011 and from the ACCP published in 2008 were compared for recommendations on the use of VKAs. A MEDLINE search from 1960 to November 2009 was conducted to identify pertinent articles on the use of warfarin or VKAs for VTE prophylaxis following THA/TKA. Search terms included warfarin, vitamin K antagonist, total hip or total knee replacement, and total hip or total knee arthroplasty.

STUDY SELECTION AND DATA EXTRACTION:

Only clinical trials in which warfarin was the primary agent for prophylaxis compared to other anticoagulants were included.

DATA SYNTHESIS:

Data on differences between guideline recommendations for the use of VKAs and the importance of a deep vein thrombosis or asymptomatic events were extracted. Thirteen comparative trials using VKAs for VTE prophylaxis and international normalized ratio (INR) targets were assessed. Overall, the incidence of bleeding tended to be lower with the use of VKAs, but thrombosis when including asymptomatic events was numerically higher when comparing INR targets. However, INR targets varied, with no comparative trials assessing the AAOS 2009 recommended INR target of 1.5-2.0. The AAOS guidelines initially recommended a longer duration of therapy and expressed stronger support for the use of aspirin for prophylaxis; however, in 2011, its guidelines were revised, with no specific recommendations as to agent, dose, or INR target goal.

CONCLUSIONS:

Warfarin is an effective agent to prevent VTE after elective THA/TKA. The most effective approach, including extended warfarin use up to 4 weeks or longer, has not been determined.

Warfarin doses for anticoagulation therapy in elderly patients with chronic atrial fibrillation

OBJECTIVE

Anticoagulation is a challenge for the prophylaxis of thromboembolic events in elderly patients with chronic atrial fibrillation. Stable anticoagulation is defined as the time within >70% of the therapeutic range. However, the dosage required to achieve stable anticoagulation remains unknown. The aim of this study was to analyze the warfarin dose necessary for the maintenance of stable oral anticoagulation therapy in elderly patients.

METHODS

We analyzed 112 consecutive outpatients with atrial fibrillation who were >65 years of age, had received anticoagulation therapy with warfarin for more than 1 year and had a stable international normalized ratio between 2.0 and 3.0 for >6 months. The international normalized ratio was measured in the central laboratory using the traditional method.

RESULTS

The patients were stratified according to the following age groups: <75 or >75 years and <80 or >80 years. The mean daily doses of warfarin were similar for patients <75 or >75 years (3.34+1.71 versus 3.26 +1.27 mg/ day, p = 0.794) and <80 or >80 years (3.36+ 1.49 versus 3.15 + 1.23 mg/day, p = 0.433). In 88 (79%) patients, the daily warfarin dose was between 2 and 5 mg/day; in 13 (11%) patients, the daily warfarin dose was <2.0 mg/day; and in 11 (10%) patients, the daily warfarin dose was >5.0 mg/day. The correlation between the daily warfarin dose and the international normalized ratio was 0.22 (p = 0.012).

CONCLUSION

Stable anticoagulation was achieved in 80% of patients who received doses of 2 to 5 mg/day of warfarin, and the mean daily dose was similar across the age groups analyzed.