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Tadesse TA, Gebremedhin A, Yadeta D, Chelkeba L, Fenta TG. Comparison of anticoagulation control and outcomes between usual medical care and pharmacist-led anticoagulation service in ambulatory patients taking warfarin at tertiary hospital in Ethiopia: a quasi-experimental study. J Pharm Health Care Sci 2024; 10:32. [PMID: 38926767 PMCID: PMC11202342 DOI: 10.1186/s40780-024-00355-9] [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: 05/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND We aimed to compare anticoagulation control and outcomes between usual medical care (UMC) and pharmacist-led anticoagulation services (PLAS) in patients receiving warfarin at the Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia. METHODS A quasi-experimental study was conducted, including 350 (66.7%) and 175 (33.3%) patients from the UMC and PLAS groups, respectively, from 525 patients. The time in therapeutic range (TTR) was determined using the Rosendaal method, with a TTR ≥ 65% set as the cut-off for optimal anticoagulation. The two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare continuous variables between groups. Categorical variables were compared between groups using Pearson's chi-square test or Fisher's exact test. Logistic regression and negative binomial regression analyses were conducted to identify the factors associated with suboptimal TTR and secondary outcomes, respectively, at the p values < 0.05, and 95% confidence interval (CI). RESULTS Compared with the UMC group, the patients in the PLAC group showed a significantly higher median (IQR) TTR [60.89% (43.5-74.69%) vs. 53.65% (33.92-69.14%), p < 0.001]. A significantly higher optimal TTR (≥ 65%) was achieved in the PLAC group (41.7% vs. 31.7%) than in the UMC group (p = 0.002). The odds of having a poor TTR were reduced by 43% (AOR = 0.57, 95% CI = 0.36-0.88, p = 0.01) among patients in the PLAC group compared to those in the UMC group. There were no statistically significant differences in the secondary outcomes between the groups, except for all-cause emergency visits (p = 0.003). The incidence of bleeding events decreased by 3% (IRR = 0.97, 95% CI = 0.96-0.99, p < 0.001) for every increase in INR monitoring frequency. The incidence of thromboembolic events increased by a factor of 15.13 (IRR = 15.13, 95% CI = 1.47-155.52, p = 0.02) among patients with a high-risk CHA2DS2-VASc score compared with those with a moderate score. CONCLUSION Patients in the PLAC group had a significantly higher median TTR than those in the UMC group did. There were no statistically significant differences in the secondary outcomes between the groups, except for fewer all-cause emergency department visits in the PLAC group.
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Affiliation(s)
- Tamrat Assefa Tadesse
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Amha Gebremedhin
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dejuma Yadeta
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Legese Chelkeba
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Alshaiban A, Alavudeen SS, Alshahrani I, Kardam AM, Alhasan IM, Alasiri SA, Imam MT, Almalki ZS, Akhtar MS. Impact of Clinical Pharmacist Running Anticoagulation Clinic in Saudi Arabia. J Clin Med 2023; 12:3887. [PMID: 37373582 DOI: 10.3390/jcm12123887] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
Despite the effectiveness of warfarin in extended anticoagulation, its narrow therapeutic index requires frequent dose adjustments and careful patient monitoring. Thus, we aimed to evaluate the outcomes of clinical pharmacists' intervention in warfarin therapy management in terms of International Normalized Ratio (INR) control, reduction of bleeding, and hospitalization in a tertiary care hospital. An observational retrospective cohort study was conducted on 96 patients taking warfarin therapy in a clinical pharmacist-led anticoagulation clinic. We observed that 39.6% of patients required dose adjustments at their first and second visits. However, dose adjustments during the third, fourth, and fifth weeks were required at 31.1%, 20.8%, and 4.2%, respectively, to achieve INR levels. We also observed that 36.46% of the patients attained the target INR at baseline, which was increased over the first week to the fifth week to 57.29%, 61.46%, 61.46%, 68.75%, and 85.42%, respectively. No one reported the ADR between the third and fifth weeks. Based on our findings, the study strongly suggests that pharmacists' interventions can improve the health-related quality of life of patients undergoing warfarin therapy. Thus, competent pharmacy personnel must be a priority in both usual patient care and critical care among primary care networks.
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Affiliation(s)
| | - Sirajudeen S Alavudeen
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Al-Fara, Abha 62223, Saudi Arabia
| | | | | | | | | | - Mohammad Tarique Imam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia
| | - Ziyad Saeed Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia
| | - Md Sayeed Akhtar
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Al-Fara, Abha 62223, Saudi Arabia
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Tadesse TA, Tegegne GT, Yadeta D, Chelkaba L, Fenta TG. Anticoagulation control, outcomes, and associated factors in long-term-care patients receiving warfarin in Africa: a systematic review. Thromb J 2022; 20:58. [PMID: 36192776 PMCID: PMC9528137 DOI: 10.1186/s12959-022-00416-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 09/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background Oral anticoagulation therapy with warfarin requires frequent monitoring level of anticoagulation by the international normalized ratio (INR). In Africa, studies that explore anticoagulation control, treatment outcomes, and associated factors are reported in various ways in long-term patients receiving warfarin therapy to generate concrete scientific evidence. Methods The literature search was conducted in PubMed, Cochrane Library, African Journal of Online databases, Google Scholar, and Google. An advanced search strategy was computed to retrieve relevant studies related to anticoagulation control and outcomes. Duplication, title and abstract screening, and full-text assessment were conducted in Covidence software. Study quality was assessed using the Joanna Briggs Institute Critical appraisal quality assessment tool. The systematic review is registered in PROSPERO (CRD42021260772) and performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. Results Out of 298 identified articles, 18 articles were eligible for the final review and analysis. The mean of 39.4 ± 8.4% time in therapeutic range (TTR) (29.4 to 57.3%), 36.7 ± 11.5% TTR (range 25.2–49.7%) and 46% TTR (43.5–48.5%) was computed from studies that determined TTR by Rosendaal, direct and cross-section-of-the-files methods, respectively. In this review, the lowest percentage of TTR was 13.7%, while the highest was 57.3%. The highest percentage of patients (32.25%) who had TTR ≥ 65% was reported in Tunisia, but the lowest percentages were in Namibia (10%, TTR ≥ 65%) and Kenya (10.4%, TTR ≥ 70%). Most of the included studies (11 out of 18) used Rosendaal’s method while the direct method was employed by three studies. Generally, 10.4–32.3% of study participants achieved desired optimal anticoagulation level. Regarding secondary outcomes, 1.6–7.5% and 0.006–59% of patients experienced thromboembolic complications and bleeding events, respectively. Having chronic comorbidities, taking more than two drugs, and presence of medications that potentially interact with warfarin, and patient-related factors (patients aged < 50 years old, female gender, lower education level, smoking history) were the frequently reported predictors of poor anticoagulation therapy. Conclusions Oral anticoagulation control was suboptimal in patients taking warfarin as evidenced by low TTR in Africa. Therefore, there is an urgent need for further improving oral anticoagulation management services. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00416-9.
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Affiliation(s)
- Tamrat Assefa Tadesse
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gobezie Temesgen Tegegne
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dejuma Yadeta
- Departmnt of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Legese Chelkaba
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Dai MF, Li SY, Zhang JF, Wang BY, Zhou L, Yu F, Xu H, Ge WH. Warfarin anticoagulation management during the COVID-19 pandemic: The role of internet clinic and machine learning. Front Pharmacol 2022; 13:933156. [PMID: 36225580 PMCID: PMC9549053 DOI: 10.3389/fphar.2022.933156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Patients who received warfarin require constant monitoring by hospital staff. However, social distancing and stay-at-home orders, which were universally adopted strategies to avoid the spread of COVID-19, led to unprecedented challenges. This study aimed to optimize warfarin treatment during the COVID-19 pandemic by determining the role of the Internet clinic and developing a machine learning (ML) model to predict anticoagulation quality. Methods: This retrospective study enrolled patients who received warfarin treatment in the hospital anticoagulation clinic (HAC) and “Internet + Anticoagulation clinic” (IAC) of the Nanjing Drum Tower Hospital between January 2020 and September 2021. The primary outcome was the anticoagulation quality of patients, which was evaluated by both the time in therapeutic range (TTR) and international normalized ratio (INR) variability. Anticoagulation quality and incidence of adverse events were compared between HAC and IAC. Furthermore, five ML algorithms were used to develop the anticoagulation quality prediction model, and the SHAP method was introduced to rank the feature importance. Results: Totally, 241 patients were included, comprising 145 patients in the HAC group and 96 patients in the IAC group. In the HAC group and IAC group, 73.1 and 69.8% (p = 0.576) of patients achieved good anticoagulation quality, with the average TTR being 79.9 ± 20.0% and 80.6 ± 21.1%, respectively. There was no significant difference in the incidence of adverse events between the two groups. Evaluating the five ML models using the test set, the accuracy of the XGBoost model was 0.767, and the area under the receiver operating characteristic curve was 0.808, which showed the best performance. The results of the SHAP method revealed that age, education, hypertension, aspirin, and amiodarone were the top five important features associated with poor anticoagulation quality. Conclusion: The IAC contributed to a novel management method for patients who received warfarin during the COVID-19 pandemic, as effective as HAC and with a low risk of virus transmission. The XGBoost model could accurately select patients at a high risk of poor anticoagulation quality, who could benefit from active intervention.
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Affiliation(s)
- Meng-Fei Dai
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Shu-Yue Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Pharmacy, Shanxi Province Cancer Hospital, Taiyuan, China
| | | | - Bao-Yan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lin Zhou
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Feng Yu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Hang Xu, ; Wei-Hong Ge,
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Hang Xu, ; Wei-Hong Ge,
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Elnour AA, Ahmed IM, Khalid AK, Elmustafa M. Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study. Pharm Pract (Granada) 2022; 20:2722. [PMID: 36733524 PMCID: PMC9851814 DOI: 10.18549/pharmpract.2022.3.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing. Objective The current study's main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects. Method We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms). Main outcome measure The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy. Results We have enrolled 71 Sudanese subjects with mean age (51.7 ± 14 years), of which (49, 69.0%) were females. There was no significant difference between the warfarin 5 mg fixed standard dose strategy and the predicted doses of the two clinical algorithm models (MAE 1.44, 1.45, and 1.49 mg/day [P =0.4]) respectively. In the clinical practicality, all of the three models had a high percent of subjects (95.0%, 51.9%, and 66.7%) in the ideal dose range in middle dose group (3-7 mg/ day) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithm models respectively. However, a small percent of subjects was exhibited in the warfarin low dose group ≤ 3 mg/day (0.0%, 15.0%, and 10.0%) and warfarin high dose group ≥ 7 mg/day (0.0%, 33.3%, and 33.3%) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithms respectively. In terms of clinical safety, the percent of subjects with severely over-prediction were 28.2%, 22.5%, and 22.5% for warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. While the percent of severely under-prediction was 12.7%, 7.0%, and 5.6% for the warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. Conclusion The Gage and IWPC clinical algorithm models were accurate, more clinically practical, and clinically safe than warfarin 5 mg standard dosing in the study population. The cardiologist can use either models (Gage and IWPC) to stratify subjects for accurate, practical, and clinically safe warfarin dosing..
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Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University (AAU), Abu Dhabi campus, Abu Dhabi-United Arab Emirates (UAE). AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Islam Mohammed Ahmed
- PhD student, MSc, B Pharm. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan. b. Faculty of Pharmacy, Managel University for Science and Technology, Managel-Sudan.
| | - Al-Kubaissi Khalid
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
| | - Mohamed Elmustafa
- PhD, Msc. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan.
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Tadesse TA, Abiye AA, Endale S, Yadeta D, Chelkeba L, Fenta TG. Challenges of Anticoagulation Management Service and Need of Establishing Pharmacist-Led Anticoagulation Clinic in Tertiary Care Teaching Hospital, Ethiopia: A Qualitative Study. J Multidiscip Healthc 2022; 15:743-754. [PMID: 35418756 PMCID: PMC8995148 DOI: 10.2147/jmdh.s359558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022] Open
Abstract
Pupose To explore the challenges of anticoagulation management (AMS) and assess the need for establishing a pharmacist-led anticoagulation clinic (PLAC) at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. Methods We conducted a qualitative study at TASH. Using a semistructured interview guide, we interviewed 15 physicians from different specialties, heads of pharmacy and laboratory departments. We also included 20 patients to explore their general perceptions, and experiences with and challenges of AMS; and the need to implement PLAC in the hospital. Results Only three physicians responded that they had protocols for initiating and maintaining warfarin dosing. Having protocols for venous thromboembolism (VTE) risk assessment, VTE prophylaxis and treatment, bleeding risk assessment, and contraindication to anticoagulant therapy were reported by seven, six, four, and three participants, respectively. Lack of trained healthcare professionals and a separate AMS clinic, inconsistency in INR testing and anticoagulant availability, and longer appointment times were the biggest challenges of the existing AMS, according to 80% of respondents. Fourteen patient respondents indicated that their satisfaction with the AMS was affected by long wait times and inconsistent availability of anticoagulants and INR testing. The head of the laboratory stated that the facilities for INR testing are inadequate and affect the quality of AMS and customer satisfaction, and supplemented by the head of the pharmacy by adding irregularities of supplies and inadequate counseling on anticoagulants. Respondents suggested that there is a need to establish a PLAC with well-adopted standard operating procedures, qualified manpower, adequate training of assigned staff, and sustained supply of anticoagulants and INR testing. Conclusion The hospital’s AMS is not optimal to provide adequate services during the study period. Based on these findings and recommendations, the supporting literature, and the experiences of other facilities, the PLAC was established in TASH.
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Affiliation(s)
- Tamrat Assefa Tadesse
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Correspondence: Tamrat Assefa Tadesse, Email
| | - Alfoalem Araba Abiye
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sisay Endale
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dejuma Yadeta
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Legese Chelkeba
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Ahmed KO, Ahmed AM, Wali MB, Ali AH, Azhari MM, Babiker A, Yousef BA, Muddather HF. Optimal Medical Therapy for Secondary Prevention of Acute Coronary Syndrome: A Retrospective Study from a Tertiary Hospital in Sudan. Ther Clin Risk Manag 2022; 18:391-398. [PMID: 35431548 PMCID: PMC9005352 DOI: 10.2147/tcrm.s361129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Five-medication regimen is recommended for patients after acute coronary syndrome (ACS) as a secondary prevention strategy at discharge to reduce recurrence and improve mortality. Objective This study aimed to assess prescribing of optimal medical therapy (OMT) as five-medication regimens for secondary prevention at discharge after ACS in Sudan. Methods A retrospective cohort study was performed at a tertiary hospital located in Wad Medani, Sudan, in the period between January and December 2019. Data were collected from patients’ files. OMT was defined as a combination of five medications; aspirin and P2Y12 inhibitors, statins, beta-blockers (BBs), and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) or if a valid contraindication was documented. Results Of the 619 patients throughout the study period, 591 were selected based on inclusion and exclusion criteria. The median age of patients was 60 years, and 58.9% of patients were male. Diabetes (44.5%) and hypertension (42%) were the most common risk factors. Most patients (58.4%) were diagnosed with ST-segment elevation myocardial infarction. About 99.7% of patients were on aspirin, 99.5% on statins, 97% on clopidogrel, 96.8% on dual antiplatelet therapy, 70.4% on BBs, and 57.9% on ACEIs/ARBs. OMT for secondary prevention was prescribed to 267 (45.2%) patients with ACS at discharge. Conclusion Although prescriptions for all five guideline-recommended medications after ACS were suboptimal, the study showed a positive trend in prescribing most individual medications.
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Affiliation(s)
- Kannan O Ahmed
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
- Correspondence: Kannan O Ahmed, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan, Tel +249 121860001, Fax +249 511861180, Email
| | - Ashraf M Ahmed
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Mojahed B Wali
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Ali H Ali
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Mustafa M Azhari
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Anas Babiker
- Department of Cardiology, Royal Care International Hospital, Khartoum, Sudan
| | - Bashir A Yousef
- Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Hiba F Muddather
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
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El-Awaisi A, Al-Shaibi S, Al-Ansari R, Naseralallah L, Awaisu A. A systematic review on the impact of pharmacist-provided services on patients' health outcomes in Arab countries. J Clin Pharm Ther 2022; 47:879-896. [PMID: 35332557 DOI: 10.1111/jcpt.13633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 01/05/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The pharmacist's role has evolved dramatically over the last few decades and shows considerable impact globally. The aim of this systematic review was to describe the nature and extent of studies evaluating the impact of pharmacist-provided services on clinical, humanistic and economic outcomes in different healthcare settings across the Arab world. METHODS A systematic literature search was conducted using the following databases from their inception until June 2020: Cochrane, Embase, MEDLINE, PubMed, ScienceDirect and Scopus. Reporting was done according to PRISMA guidelines, and the quality assessment utilized the Mixed Methods Appraisal Tool. RESULTS AND DISCUSSION Thirty-five eligible studies were included in this review, the majority of which were randomized controlled trials (RCT) (n = 26) conducted in hospital settings (n = 26). Most of the studies involved patients with specific medical conditions (n = 29) and pharmacist's interventions involved mainly medication therapy management (n = 32), counselling and education (n = 29), and medication therapy recommendations (n = 12). Several studies showed a positive impact (i.e., a statistically and/or clinically significant difference in favour of pharmacist-provided care or intervention) of pharmacist-provided services on clinical (n = 28), humanistic (n = 6) and economic (n = 5) outcomes. Conversely, five studies showed neutral or mixed effect of pharmacist interventions on clinical and humanistic outcomes. WHAT IS NEW AND CONCLUSION The findings of this systematic review demonstrate a positive impact of pharmacist-provided services on clinical, humanistic and economic outcomes across diverse settings in the Arab world. Most of the included studies evaluated clinical outcomes and were from hospital setting. Directed approaches are needed to advance pharmacy practice across various healthcare settings in the Arab world.
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Affiliation(s)
- Alla El-Awaisi
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Samaher Al-Shaibi
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | | | - Lina Naseralallah
- Pharmacy Department, Hamad Medical Cooperation, Doha, Qatar.,School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Fan X, Chen D, Bao S, Bai R, Fang F, Dong X, Zhang Y, Zhang X, Ma Y, Zhai X. Integrating Multidisciplinary Individualized Medication Recommendations Into the Traditional Pharmacists' Consultation Method: A Retrospective Study Using Propensity Score Matching Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580221081437. [PMID: 35610968 PMCID: PMC9136448 DOI: 10.1177/00469580221081437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chinese clinical pharmacists consider improving the quantity and quality of consultations to be an important task in providing better pharmaceutical care. To achieve this goal, we developed a clinical pharmacist consultation method using multidisciplinary individualized medication recommendations (MIMRs) and studied the effects of its implementation. A retrospective study of 812 clinical pharmacist-led consultations was conducted. In the pre-intervention group, medication advice was given based on the purpose of the consultation. In the post-intervention group, a consultation method using MIMRs was implemented, in which clinical pharmacists with specialties in anticoagulation, gastroenterology, and nutrition were asked to give individualized medication recommendations. Outcomes, including the effectiveness rate of consultations (ERC) and acceptance rate of consultations (ARC), were compared between the two groups using propensity score matching method. Patterns and numbers of consultations and individualized medication recommendations were also compared. The results showed that the ERC in the post-intervention group compared with the ERC in the pre-intervention group was 83.3% vs 74.0%, respectively (P < .05). Significant difference was also shown between the two groups in ARC (98.4% vs 92.2%, P < .05). The total number of consultations increased, as did the number of general consultations, multidisciplinary/difficult consultations, anti-infection consultations, and non–anti-infection consultations specifically. As a result, we proposed that the implementation of MIMRs can improve the effects of treatment and increase the number of consultations by pharmacists, which is worthy of further promotion to better serve physicians and patients.
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Affiliation(s)
- Xiucong Fan
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Danxia Chen
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Siwei Bao
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Rong Bai
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Fang Fang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaohui Dong
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Yuyi Zhang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaogang Zhang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Yabin Ma
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaobo Zhai
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
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10
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Mouton JP, Blockman M, Sekaggya-Wiltshire C, Semakula J, Waitt C, Pirmohamed M, Cohen K. Improving anticoagulation in sub-Saharan Africa: What are the challenges and how can we overcome them? Br J Clin Pharmacol 2021; 87:3056-3068. [PMID: 33586223 PMCID: PMC8359270 DOI: 10.1111/bcp.14768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/04/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Patients in sub-Saharan Africa generally have poor anticoagulation control. We review the potential reasons for this poor control, as well as the potential solutions. Challenges include the affordability and centralisation of anticoagulation care, problems with access to medicines and international normalised ratio monitoring, the lack of locally validated standardized dosing protocols, and low levels of anticoagulation knowledge among healthcare workers and patients. Increasing numbers of patients will need anticoagulation in the future because of the increasing burden of noncommunicable disease in the region. We propose that locally developed "warfarin care bundles" which address multiple anticoagulation challenges in combination may be the most appropriate solution in this setting currently.
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Affiliation(s)
- Johannes P Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Jerome Semakula
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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11
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Njuguna B, Berhane H, Ndemo FA, Opanga S. Scaling up clinical pharmacy practice in Africa: Current challenges and the future. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Benson Njuguna
- Department of Pharmacy & Department of Cardiology Moi Teaching & Referral Hospital Eldoret Kenya
| | - Haftay Berhane
- Mekelle University College of Health Sciences and Ayder Comprehensive Specialized Hospital Mekelle Ethiopia
| | - Francis Abuga Ndemo
- School of Pharmacy and Health Sciences, United States International University Nairobi Kenya
| | - Sylvia Opanga
- Division of Clinical Pharmacy, School of Pharmacy University of Nairobi Nairobi Kenya
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12
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Ndadza A, Thomford NE, Mukanganyama S, Wonkam A, Ntsekhe M, Dandara C. The Genetics of Warfarin Dose-Response Variability in Africans: An Expert Perspective on Past, Present, and Future. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 23:152-166. [PMID: 30883300 DOI: 10.1089/omi.2019.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Coumarins such as warfarin are prescribed for prevention and treatment of thromboembolic disorders. Warfarin remains the most widely prescribed and an anticoagulant of choice in Africa. Warfarin use is, however, limited by interindividual variability in pharmacokinetics and a narrow therapeutic index. The difference in patients' pharmacodynamic responses to warfarin has been attributed to genetic variation in warfarin metabolism and molecular targets (e.g., CYP2C9 and VKORC1) and host-environment interactions. This expert review offers a synthesis of human genetics studies in Africans with respect to pharmacogenetics-informed warfarin dosing. We identify areas that need future research attention or could benefit from harnessing existing pharmacogenetics knowledge toward rational and optimal therapeutics with warfarin in African patients. A literature search was conducted until January 2019. A total of 343 articles were retrieved from nine African countries: Botswana, Ethiopia, Egypt, Ghana, Kenya, South Africa, Sudan, Tanzania, and Mozambique. We found 19 studies on genetics of warfarin treatment specifically among Africans. Genes examined included CYP2C9, VKORC1, CYP4F2, APOE, CALU, GGCX, and EPHX1. CYP2C9*2 and *3 alleles were highly frequent among Egyptians, while rare in other African populations. CYP2C9*5, *8, *9, and *11, and VKORC1 Asp36Tyr genetic variants explained warfarin variability in Africans better, compared to CYP2C9*2 and *3. In Africa, there is limited pharmacogenetics data on warfarin. Therefore, future research and funding commitments should be prioritized to ensure safe and effective use of warfarin in Africa. Lessons learned in Africa from the science of pharmacogenetics would inform rational therapeutics in hematology, cardiology, and surgical specialties worldwide.
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Affiliation(s)
- Arinao Ndadza
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nicholas Ekow Thomford
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Ambroise Wonkam
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mpiko Ntsekhe
- 3 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Collet Dandara
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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13
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Metaxas C, Albert V, Habegger S, Messerli M, Hersberger KE, Arnet I. Patient Knowledge about Oral Anticoagulation Therapy Assessed during an Intermediate Medication Review in Swiss Community Pharmacies. PHARMACY 2020; 8:pharmacy8020054. [PMID: 32231095 PMCID: PMC7355591 DOI: 10.3390/pharmacy8020054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Therapy with oral anticoagulation (OAC) can be challenging, especially in high risk groups such as chronic patients. Gaps in patient knowledge about OAC are linked to reduced effectiveness and safety of treatment. The objectives of this study were i) to assess OAC knowledge gathered during an intermediate medication review (MR) in patients taking vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC); ii) to assess OAC knowledge two weeks after the MR, and iii) to evaluate patient satisfaction with the MR service in community pharmacies. Methods: Chronic OAC patients were invited for a regular MR service in Swiss community pharmacies, the so-called “Polymedication-Check” (PMC). OAC knowledge was assessed with seven newly generated items asked face-to-face during a PMC and by telephone two weeks later. Knowledge gaps, pharmacists’ spontaneous interventions, and patient satisfaction were documented by observing pharmacy students. Treatment groups were compared. Results: Of all patients (n = 81), the number of patients with one or more knowledge gaps decreased from 66% to 31.3% after PMC (p < 0.001). NOAC patients (n = 31) had more knowledge gaps than VKA patients (n = 50; p < 0.05). Most patients (98.6%) were satisfied with the counselling provided by the pharmacists. Conclusion: The majority of chronic OAC patients shows knowledge gaps. Although spontaneous, the provision of tailored education during a PMC increased patient OAC knowledge.
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Roseau C, Richard C, Renet S, Kowal C, Eliahou L, Rieutord A, Chaumais MC. Evaluation of a program of pharmaceutical counseling for French patients on oral anticoagulant therapy. Int J Clin Pharm 2020; 42:685-694. [PMID: 31933106 DOI: 10.1007/s11096-020-00964-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
Background Oral anticoagulants are widely used for treatment and prevention of thromboembolic diseases. We set up a pharmaceutical counseling program for both direct oral anticoagulant and vitamin K antagonist drugs in our hospital in 2015. Objective Evaluate patient satisfaction and the evolution of their knowledge throughout the pharmaceutical counseling program on anticoagulants and identify knowledge variability factors. Setting Cardiology Inpatient Unit from the University Antoine Béclère Hospital, France. Methods Evaluation was based on data collection of patients surveyed between 2015 and 2018. Inpatients in the cardiology department on oral anticoagulants were eligible. The learning process was designed to enhance patient knowledge and understanding based on 10 cognitive or self-management skills, relating to the optimization of oral anticoagulant therapy management. It consisted in 2 face-to-face interviews during hospitalization and 2 additional phone interviews one and six months after discharge. The median patient score was evaluated at each step of the process as well as the mean score for each item from the global population. A sub-analysis was run on the less well-acquired skills in order to identify risk factors for limited knowledge. The association between those factors and the level of knowledge (score ≥ 7 or < 7) was assessed using Chi square test followed by multivariate analysis. Main outcome measure Patient knowledge of anticoagulation therapy depending on specific factors. Results Of the 880 patients eligible for pharmaceutical counseling, 319 entered the process and 102 completed it. Median knowledge scores were 8/10 and 9/10 after the first and the final interviews respectively with a significant improvement (p = 0.0003). The least well-acquired items at each step were surveillance and under-dosing management. The sub-analysis showed the use of vitamin K antagonist to be linked to an enhanced understanding related to treatment surveillance (p = 0.029). Patients suffering from atrial fibrillation were found to have a worse understanding of under-dosing management (p = 0.013). Finally, patients evaluated the process as helpful and suitable for their conditions. Conclusion Pharmaceutical counseling is appropriate for patients, improving and maintaining knowledge of oral anticoagulants. Our evaluation highlights the need to focus on patient-specific profiles to reach a satisfactory level of knowledge.
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Affiliation(s)
- C Roseau
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - C Richard
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - S Renet
- Service de Pharmacie, Groupe Hospitalier Paris Saint-Joseph, Paris, France.,Univ. Paris-Sud, Faculté de Pharmacie, Université Paris-Saclay, Châtenay Malabry, France
| | - C Kowal
- AP-HP, Service de pharmacie, Hôpital Albert Chenevier, Creteil, France
| | - L Eliahou
- AP-HP, Service de cardiologie, Hôpital Antoine Béclère, Clamart, France
| | - A Rieutord
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - M-C Chaumais
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France. .,Univ. Paris-Sud, Faculté de Pharmacie, Université Paris-Saclay, Châtenay Malabry, France. .,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
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15
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Anakwue R. Anticoagulation in sub-saharan africa with the advent of non-vitamin K antagonist oral anticoagulants. NIGERIAN JOURNAL OF MEDICINE 2020. [DOI: 10.4103/njm.njm_12_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Outcomes of warfarin therapy managed by pharmacists via hospital anticoagulation clinic versus online anticoagulation clinic. Int J Clin Pharm 2018; 40:1072-1077. [PMID: 29956134 DOI: 10.1007/s11096-018-0674-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 06/14/2018] [Indexed: 12/25/2022]
Abstract
Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P = 0.393) and adverse events [major bleeding events (0 vs. 1.2%, P = 1.000), minor bleeding events (10.0 vs. 9.8%, P = 0.960), thromboembolic events (0 vs. 0%, P = 1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P = 1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P = 1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P = 0.148), and extreme total (8.4 vs. 5.8%, P = 0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P = 0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P = 0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.
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