Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey

Assessment of knowledge and counseling practice of warfarin among pharmacists in UAE: A cross-sectional study

Objective Background

Warfarin has long been regarded as the cornerstone anticoagulant for patients requiring long-term prevention or treatment of thromboembolic disorders. With adequate knowledge and counseling skills, hospital and community pharmacists can play a major role in enhancing warfarin therapy.

Objective

to evaluate the knowledge and counseling practices toward warfarin among community and hospital pharmacists in UAE.

Methods

A cross-sectional study involving community and hospital pharmacies was conducted with online questionnaire which was submitted to pharmacists focusing on their pharmacotherapeutic knowledge and patient education toward warfarin in UAE. Data were collected within 3 months (July, August and September 2021). SPSS Version 26 was used to analyze the data. The survey questions were sent to expert researchers in pharmacy practice for comments on their relevancy, clarity, and essentiality.

Results

Among the target population sample size of 400 pharmacists were approached. Majority of the pharmacists in UAE (157/400, 39.3%) had 1-5 years of experience. Most of the participants (52%) have fair knowledge about warfarin and (62.1%) of them have fair counseling practices about warfarin. Hospital pharmacists have more knowledge than community pharmacists (Mean rank, Independent pharmacy: 166.30, Chain pharmacy: 138.01, Hospital pharmacy: 252.27, p<0.05) and they have better counseling practice than community pharmacists (Mean rank, Independent pharmacy: 188.83, Chain pharmacy: 170.18, Hospital pharmacy: 222.90, p<0.05).

Conclusion

The study's participants had moderate knowledge and counseling practices of warfarin. As a result, specialized training in warfarin therapy management for pharmacists is needed to improve therapeutic outcomes and avoid complications. Moreover, conferences or online courses should be held to train pharmacists on how to provide professional counseling to patients.

The Dilemma of Peri-Procedural Warfarin Management: A Narrative Review

Periprocedural vitamin K antagonist management is a complex process and inherently entails multiple clinical issues. Marked variations have been reported in different aspects of this process. These differences were noted at the clinician and institutional levels owing to the lack of evidence-based data leading to many discrepancies in decision-making. This review aims to address the gap of vitamin K antagonist periprocedural management acknowledged by previously published prescribers’ questionnaires. One of the components of this process is “bridging,” which aims to provide minimal interruption of the anticoagulation period through the use of heparin products. Recent studies showed that bridging is increasing bleeding risk. Secondly, interruption decision relies on the classification of thromboembolism risk which depends on trials that did not include patients with atrial fibrillation. Thirdly, the interruption duration is different among different International normalization ratio levels, which strengthens the difference in the clinical practice of preoperative vitamin K antagonist management. Lastly, the resumption of a vitamin-K antagonist after surgery has many scenarios according to the procedure and patient risk of bleeding. Vitamin-K antagonist periprocedural management is complicated due to individual practice and the lack of strictly implemented institutional standardized protocols to guide, manage and evaluate the process.

Bridging vs Non-Bridging with Warfarin Peri-Procedural Management: Cost and Cost-Effectiveness Analyses

The warfarin peri-procedural management in Qatar is predominantly based on bridging (63%), compared to non-bridging. This study sought to perform a first-time cost analysis of current warfarin peri-procedural management practices, including a cost-effectiveness analysis (CEA) of predominant bridging vs predominant non-bridging practices. From the hospital perspective, a one-year decision-analytic model followed the cost and success consequences of the peri-procedural warfarin in a hypothetical cohort of 10,000 atrial fibrillation patients. Success was defined as survival with no adverse events. Outcome measures were the cost and success consequences of the 63% bridging (vs not-bridging) practice in the study setting, ie, Hamad Medical Corporation, Qatar, and the incremental cost-effectiveness ratio (ICER, cost/success) of the warfarin therapy when predominantly bridging based vs when predominantly non-bridging based. The model was based on Monte Carlo simulation, and sensitivity analyses were performed to confirm the robustness of the study conclusions. As per 63% bridging practices, the mean overall cost of peri-procedural warfarin management per patient was USD 3,260 (QAR 11,900), associated with an overall success rate of 0.752. Based on the CEA, predominant bridging was dominant (lower cost, higher effect) over the predominant non-bridging practice in 62.2% of simulated cases, with a cost-saving of up to USD 2,001 (QAR 7,303) at an average of USD 272 (QAR 993) and was cost-effective in 36.9% of cases. Being between cost-saving and cost-effective, compared to predominant non-bridging practices, the predominant use of bridging with warfarin seems to be a favorable strategy in atrial fibrillation patients.

Periprocedural Anticoagulation Management of Patients receiving Warfarin in Qatar: A Prospective Cohort Study

BACKGROUND

The use of anticoagulant bridging remains controversial. This study was conducted to evaluate our warfarin periprocedural management in Qatar and investigate the associated clinical outcomes with such management.

METHODS

A prospective cohort study was designed to describe the periprocedural clinical practice in warfarin patients in Qatar and to compare clinical safety and efficacy outcomes between anticoagulant bridging and nonbridging.

RESULTS

103 patients were recruited. Bridging occurred in 82% of the participants. No thromboembolic events were observed, while 39.1% of patients experienced bleeding events during the study period. The incidence of overall bleeding and major bleeding were numerically higher for bridging group compared to nonbridging but did not reach statistical significance ([30.6% vs 22.2%, P = 0.478] and [12.9% vs 5.6%, P = 0.375], respectively).

CONCLUSION

Warfarin interruption and bridging are overwhelmingly used in warfarin-treated patients in Qatar. While bridging was numerically associated with increased bleeding events, there is no statistical difference in reported clinical events between bridging and nonbridging strategies.