ASSESSMENT OF TIME IN THERAPEUTIC RANGE WITH WARFARIN THERAPY IN PHARMACIST VERSUS USUAL CARE GROUP: A RETROSPECTIVE COHORT STUDY
DOI:
https://doi.org/10.22159/ajpcr.2020.v13i7.37669Keywords:
Warfarin, Time in therapeutic range, International normalized ratio, pharmacist, Medication therapy management, Atrial fibrillationAbstract
Objective: Anticoagulation management with warfarin is a familiar challenge seen in primary care settings. A greater time in the therapeutic range (TTR) has shown improved health benefits in patients treated with warfarin for atrial fibrillation. The aim of this study was to assess the level of anticoagulation control achieved with warfarin therapy measured by TTR.
Methods: Patients attending anticoagulation service at a medical center were included in this retrospective cohort study. Patients with at least two international normalized ratio (INR) values not more than 4 weeks apart were included and placed in a usual care group or a pharmacist care group based on the care received. Anticoagulation control was measured by calculating TTR according to Roosendaal’s linear interpolation method. A TTR of >70% was considered high-quality and >60% was considered moderate coagulation control. The data were analyzed for descriptive statistics, associations, and for identifying predictors of TTR. A p value of <0.05 was considered statistically significant.
Results: Mean age of patients was 58±9 years; 57% were male; 48% were White Caucasian, and 43% had a CHADS2 score of ≥3. Patients in the pharmacist group had a high TTR (67.6% vs. 43.4%, p<0.0001) and an INR in a significantly lower sub-therapeutic range than the usual care group (5.6% vs. 14.8%; p<0.0001). Half of the patients in the pharmacist group were able to achieve a TTR threshold of 60% and greater compared to less than one-third among the usual care group. Age and pharmacist care were found to be great predictors of TTR after adjusting for gender, ethnicity, and CHADS2 score (p<0.001).
Conclusion: Our findings confirmed that pharmacist led anticoagulation care positively improved patients’ TTR with warfarin.
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Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, et al. Secular trends in incidence of atrial fibrillation in Olmsted county, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006;114:199-25.
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and risk factors in atrial fibrillation (ATRIA) study. JAMA 2001;285:2370-75.
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: A report from the American heart association. Circulation 2019;139:e56-528.
Multiple Cause of Death Data, 1999-2018. Centers for Disease Control and Prevention, National Center for Health Statistics. Available from: https://www.onder.cdc.gov/wonder/help/mcd.html. [Last accessed on 2019 Dec 20].
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics-2015 update: A report from the American heart association. Circulation 2015;131:e29-322.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: Results from the national registry of atrial fibrillation. JAMA 2001;285:2864-70.
Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, et al. Evidence-based management of anticoagulant therapy. CHEST 2012;141:e152S-84.
Gateman D, Trojnar M, Agarwal G. Time in therapeutic range: Warfarin anticoagulation for atrial fibrillation in a community-based practice. Can Fam Physician 2017;63:e425-31.
Vestergaard AS, Skjøth F, Larsen TB, Ehlers LH. The importance of mean time in therapeutic range for complication rates in warfarin therapy of patients with atrial fibrillation: A systematic review and meta-regression analysis. PLoS One 2017;12:e0188482.
Hylek EM, Skates SJ, Sheehan MA, Singer DE. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med 1996;335:540-6.
White HD, Gruber M, Feyzi J, Kaatz S, Tse HF, Husted S, et al. Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: Results from SPORTIF III and V. Arch Intern Med 2007;167:239-45.
Saokaew S, Sapoo U, Nathisuwan S, Chaiyakunapruk N, Permsuwan U. Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand. Int J Clin Pharm 2012;34:105-12.
Rosendaal FR, Cannegieter SC, van der Meer FJ, Briet E. A method to determine the optimal intensity of oral anticoagulation therapy. Thromb Haemost 1993;69:236-9.
Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest 2018;154:1121-201.
IBM. SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM; 2017.
Lee JC, Horner KE, Krummel ML, McDanel DL. Clinical and financial outcomes evaluation of multimodal pharmacist warfarin management of a statewide urban and rural population. J Pharm Pract 2017;31:150-6.
Tran NT, Lin CH, Do NN, Muradian IK, Lu QD, Henderson SO. The Impact of implementing an advance practice pharmacist-led anticoagulation clinic within a correctional facility. J Pharm Pract 2019. Doi: 10.1177/0897190019892120.
Liang JB, Lao CK, Tian L, Yang YY, Wu HM, Tong HH, et al. Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: A randomised controlled trial. Int J Pharm Pract 2020;28:97-106.
Mifsud EM, Wirth F, Camilleri L, Camilleri L, Serracino-Inglott A. Pharmacist-led medicine use review in community pharmacy for patients on warfarin. Int J Clin Pharm 2019;41:741-50.
Mckenzie JA, Wilson-Clarke C, Prout J, Campbell J, Douglas RD, Gossell-Williams M. Improving warfarin therapy through implementation of a hospital-based pharmacist managed clinic in Jamaica. Pharm Pract (Granada) 2018;16:1214.
Dlott JS, George RA, Huang X, Odeh M, Kaufman HW, Ansell J, et al. National assessment of warfarin anticoagulation therapy for stroke prevention in atrial fibrillation. Circulation 2014;129:1407-14.
Falamić S, Lucijanić M, Hadžiabdić MO, Marušić S, Vrca VB. Pharmacist’s interventions improve time in therapeutic range of elderly rural patients on warfarin therapy: A randomized trial. Int J Clin Pharm 2018;40:1078-85.
Phelps E, Delate T, Witt DM, Shaw PB, McCool KH, Clark NP. Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service. Thromb Res 2018;163:54-9.
Marcatto LR, Sacilotto L, Tavares LC, Facin M, Olivetti N, Strunz CM, et al. Pharmaceutical care increases time in therapeutic range of patients with poor quality of anticoagulation with warfarin. Front Pharmacol 2018;9:1052.
de Lima Silva RG, Bertollo CM, Ferreira IG, Brant CD, Martins MA. Assessment of oral anticoagulation control at two pharmacist-managed clinics in Brazil. Int J Clin Pharm 2017;39:1157-61.
Odashiro K, Yokoyama T, Fukata M, Arita T, Maruyama T, Akashi K. Anticoagulation stability depends on CHADS2 score and hepatorenal function in warfarin-treated patients, including those with atrial fibrillation. J Atheroscler Thromb 2017;24:68-76.
Saokaew S, Permsuwan U, Chaiyakunapruk N, Nathisuwan A, Sukonthasarn A. Effectiveness of pharmacist-participated warfarin therapy management: A systematic review and meta-analysis. J Thromb Haemost 2010;8:2418-27.
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