Safer anticoagulation management in the community : a pharmacist-led approach

Abstract

Therapeutic monitoring in patients on warfarin is essential to enhance treatment efficacy with less complications. Medicine use review (MUR) enables individualised patient assessment to check and balance drug-related problems (DRPs). The aim of this research was to develop and implement a pharmacist-led MUR for patients on warfarin, assess patient knowledge and adherence, and address identified risks with prescribed treatment. Patients on warfarin attended a structured MUR session, during which baseline information to assess patient knowledge and adherence to warfarin treatment was collected. Point-of-care INR testing was performed with the CoaguChek®XS device. Medication reconciliation was performed to identify DRPs and to recommend clinical interventions. Patients were followed-up after two months to evaluate the impact of pharmacist intervention and degree of implementation of the pharmacist researcher‟s recommendations by the physician, pharmacist or patient. A total of 100 patients (56 male, 44 female; mean age 70.5 ±10.30, range 33-89 years) were assessed. Forty patients had an INR value outside the target range. The mean score in the warfarin knowledge test improved significantly from 7 to 10 points out of 12 post-intervention (p<0.05). The number of patients who were non-adherent to warfarin decreased from 25 to 11 post-intervention (p<0.05). Post-intervention a significant improvement in INR control was observed where time spent within therapeutic range increased from 69% to 80% (p<0.05). A total of 632 medications were reconciled (mean 6 ±2.76, range 1-16 medications/patient). A total of 481 DRPs (mean 5 ±1.83, range 0-9 DRPs/patient) were identified, out of which 40% were related to warfarin. Need for monitoring (30%), lack of compliance (20%) and need for patient education (19%) were the top three DRPs identified. Eighty-four percent of the pharmacist researcher‟s recommendations were accepted, 20% of which resulted in changes to drug treatment. Ninety patients would be willing to use the proposed MUR service, if implemented. Improvement in patient knowledge, adherence, INR control and the high proportion of implemented recommendations suggest that pharmacist-led MUR improves therapeutic outcomes and patient safety.