Pharmacist trumps family physician care for anticoagulation patients
MedWire News: Patients on anticoagulation therapy experience better control of their condition when it is managed by a pharmacist with specific expertise, than when it is done by a family physician giving usual care (UC), report researchers.
In particular, patients given pharmacist care (PC) had international normalized ratio (INR) values significantly more frequently in the therapeutic and expanded range than patients given UC.
"Based on the results of this study, a collaborative family practice clinic using pharmacists and physicians may be an effective structure for an anticoagulation management service," suggest Stephanie Young (Memorial University, St John's, Newfoundland and Labrador, Canada) and co-workers.
The team carried out a retrospective review of data for patients on anticoagulation therapy treated during a 17-month period at a family medicine clinic by either PC (2006-7, n=112) or UC (prior to 2006, n=81).
UC comprised a blood test for INR testing, which was processed at the local hospital, after which physicians called their patients, directly or via clinic staff, to inform them of the results. No specific dosing regimen for warfarin treatment was used, instead, physicians relied on their knowledge and experience.
The pharmacists who gave PC had completed two specific short courses in anticoagulation management and produced clinic-specific protocols based on current guidelines. Protocols included dosage recommendations and time intervals between INR testing, but allowed flexibility for patient individuality, explain Young et al.
PC patients also underwent hospital blood tests, and were informed of the results by the pharmacist who then used the protocol guidelines as well as clinical judgment to develop a warfarin dosing plan, provide follow-up INR testing, and give patient counseling.
The most common indications for warfarin among all patients were atrial fibrillation, mechanical heart valves, and deep vein thrombosis. The number of INR tests undertaken per year were 29 and 25 in the PC and UC groups, respectively. The corresponding number of INR tests during this period that were more than 6 weeks apart were 1.3 and 1.8.
Overall, the PC group spent significantly more time in the recommended therapeutic range (TTR) for INR (2.0-3.0 or 2.5-3.5 according to indication for therapy) than the UC group, at 73.4 versus 64.8%, and in the expanded therapeutic range (TTR ±0.3), at 90.8% versus 84.8%.
The percentage of time patients' INR was less than 1.5 was less for those in the PC compared with the UC group, at 0.67 versus 1.92%. However, more PC patients than UC patients spent time with an INR of greater than 5.0, at 0.27 versus 0.08%.
Two major bleeding events occurred in the PC group, an abdominal hematoma and a lower gastrointestinal bleed, note the researchers. No such events occurred in the UC-treated group.
"The results of our study indicate that both models of care provided high quality anticoagulation management," write the study authors in the journal BMC Family Practice.
However, they highlight the statistical significance of the greater time spent in the TTR and expanded TTR for PC patients versus UC patients.
The results show support for anticoagulation management by a pharmacist "who applies a systematic, evidence based approach to patient care," the team concludes.
By Sarah Guy