Cost-effectiveness of the pharmacist-assisted warfarin monitoring program at a Medical Center in Taiwan

Clinical, economic, and humanistic impact of a multidisciplinary medication review with follow-up for anticoagulated patients treated with vitamin K antagonists in primary care: A cluster randomised controlled trial

BACKGROUND

Interdisciplinary collaboration between general practitioner, nurses and pharmacists can favour the control of patients treated with vitamin K antagonists (VKA), increasing their safety and effectiveness. The aim of the study was to evaluate the impact of pharmaceutical interventions on patients treated with VKA within the framework of a Pharmacotherapeutic Follow-up service on clinical, economic and humanistic outcomes.

METHODS

Controlled and randomized study in patients from two health areas of Zaragoza in treatment with VKA with Time in Therapeutic Range (TTR) according to the Rosendaal method less than 70% in the last 6 months. Patients were recruited at the pharmacy and assigned to two groups: control and intervention. A Pharmacotherapeutic Follow-up Program was established for the intervention group for 6 months. The outcome variables were INR stability, pharmacological adherence, vitamin K intake, knowledge about the use of acenocoumarol, quality of life, satisfaction with treatment, associated costs and avoided costs. A descriptive analysis was performed, and the Students' T test or Mann-Whitney U test was used for the association between quantitative variables and Chi-square or Fisher's test for qualitative variables.

RESULTS

A total of 123 patients were included, 65 in the intervention group (IG) and 58 in the control group (CG). A total of 108 interventions were conducted (1.7 interventions/patient) and the most common were those related to the proper taking of medications (41.0%). In IG, TTR (p = 0.019), adherence to treatment (p = 0.038) and knowledge about acenocoumarol (p = 0.031) improved, compared to CG. A higher proportion of patients in IG achieved a TTR>65% (p = 0.024). In addition, patients whose interventions were accepted by the physician (p = 0.027) and those who received vitamin K optimization interventions (p = 0.003) achieved TTR>65% in greater proportion.

CONCLUSIONS

Community pharmacist medication review, in collaboration with general practitioners improve knowledge and adherence of patients treated with oral anti-vitamin K agents and enhances the achievement of their therapeutic INR ranges. Investment needed to achieve this clinical impact is low and patient satisfaction is high.

TRIAL REGISTRATION

This study has been registered with Clinical Trials.gov dated 25/05/2017: NCT03154489.

Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020)

BACKGROUND

Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment.

AIM

To conduct a systematic review of literature on economic evaluation of pharmacy services.

METHOD

Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA).

RESULTS

Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11).

CONCLUSION

The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.

A systematic review of economic evaluations of pharmacist services

BACKGROUND

Challenges to the provision of health care are occurring internationally and are expected to increase in the future, further increasing health spending. As pharmacist roles are evolving and expanding internationally to provide individualised pharmaceutical care it is important to assess the cost-effectiveness of these services.

OBJECTIVES

To systematically synthesise the international literature regarding published economic evaluations of pharmacy services to assess their cost-effectiveness and clinical outcomes.

METHODS

A systematic review of economic evaluations of pharmacy services was conducted in MEDLINE, EMBASE, PubMed, Scopus, Web of Science, CINAHL, IPA and online journals with search functions likely to publish economic evaluations of pharmacy services. Data were extracted regarding the interventions, the time horizon, the outcomes and the incremental cost-effectiveness ratio. Studies' quality of reporting was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement.

RESULTS

Seventy-five studies were included in the systematic review, including 67 cost-effectiveness analyses, 6 cost-benefit analyses and 2 cost-consequence analyses. Of these, 57 were either dominant or cost-effective using a willingness-to-pay threshold of NZ$46 645 per QALY. A further 11 studies' cost-effectiveness were unable to be evaluated. Interventions considered to be most cost-effective included pharmacist medication reviews, pharmacist adherence strategies and pharmacist management of type 2 diabetes mellitus, hypertension and warfarin/INR monitoring. The quality of reporting of studies differed with no studies reporting all 28 items of the CHEERS statement.

CONCLUSIONS

There is strong economic evidence to support investment in extended pharmacist services, particularly those focussed on long-term chronic health conditions.

Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective

Background

Despite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt.

Methods

A prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider’s perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually.

Results

The study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9–100%] vs. 73.1% (52.7–95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of −72.5796 for the intervention group.

Conclusion

The PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT04409613].

The Impact of Pharmacist-Managed Service on Warfarin Therapy in Patients after Mechanical Valve Replacement

OBJECTIVE

To evaluate the impact of pharmacist interventions on international normalized ratio (INR) control during the warfarin initiation phase after mechanical valve replacement.

METHODS

This was a retrospective cohort study conducted in a cardiovascular surgery ward in a tertiary hospital from August 1, 2015, to July 31, 2019. Patients aged ≥20 years who were admitted for mechanical valve replacement were enrolled in this study and further classified into conventional and pharmacist-managed warfarin therapy (PMWT) groups. All participants were prospectively followed up until the first outpatient appointment after valve replacement. The effectiveness outcomes were time in therapeutic range (TTR), time to therapeutic INR, number of patients with therapeutic INR at discharge and at first outpatient appointment, and length of hospital stay. The safety outcome was the number of patients with any supratherapeutic INR during the hospital stay. Multivariate logistic regression analyses were also used to determine the predictors of a therapeutic INR at discharge or with any supratherapeutic INR during admission.

RESULTS

A total of 39 and 33 patients were enrolled in the conventional and PMWT groups, respectively. At discharge, 18 patients (46.2%) in the conventional group and 24 patients (72.7%) in the PMWT group had achieved the therapeutic INR (P=0.023). Compared to the conventional group, fewer patients in the PMWT group had supratherapeutic INR during hospital stay (35.9% vs. 9.0%, P=0.008). No significant differences were found in TTR, time to therapeutic INR, number of patients with therapeutic INR at return appointment, and length of stay between the study groups. In the multivariate regression analyses, PMWT predicted achieving therapeutic INR at discharge (odds ratio (OR) and 95% confidence interval (CI), 3.14 [1.08-9.14]) and was inversely associated with supratherapeutic INRs during admission (OR = 0.21 [0.05-0.82]).

CONCLUSIONS

Among patients admitted for mechanical valve replacement, the implementation of PMWT was associated with optimal therapeutic INR at discharge and no supratherapeutic INR during admission. Therefore, pharmacist participation is essential for improving the quality of warfarin therapy.

Pharmacists views on participating in New Zealand's community pharmacy anticoagulation management service: a mixed-methods study

Background Optimal anticoagulation management is key for improving outcomes. The Community Pharmacy Anticoagulation Management Service (CPAMS) has beneficial effects on anticoagulant management. However, limited research exists on pharmacists' views of CPAMS provision, particularly the perspectives of pharmacists who do not provide CPAMS. Objectives To explore the experience and attitudes of pharmacists who do and do not provide CPAMS, and to identify factors that may influence further uptake of CPAMS. Setting CPAMS providing and non-providing pharmacies throughout New Zealand. Methods A mixed-methods study design was employed. Separate online surveys were conducted with CPAMS providers (N = 35) and non-providers (N = 73) to explore their views on the service. Twelve interviews were conducted with purposively selected participants, equally distributed between CPAMS providers and non-providers, to gain further insight into the issues surrounding CPAMS provision. Quantitative data were analysed using student's t-test and Mann Whitney U-test, and thematic analysis was used for qualitative data. Main outcome measure Experiences of and attitudes towards CPAMS. Results Our survey findings demonstrated that community pharmacists have high self-efficacy and motivation to providing CPAMS, and CPAMS had increased job satisfaction amongst providers. The overwhelming majority of CPAMS providers' survey participants believed that CPAMS improves the pharmacist-patient relationship, allowing them to assist patients with other aspects of their healthcare. Most non-provider survey participants also believed that their patients would benefit from CPAMS. The two most frequently reported barriers by non-providers survey participants were remuneration and staffing of pharmacists. The interview findings fell within five overarching themes: self-efficacy, CPAMS benefits to patients, barriers to providing CPAMS, the impact of CPAMS on pharmacist-patient and pharmacist-general practitioner relationships. Overall, the current funding model, the capping on the number of enrolled patients, and staffing were the main factors perceived by interview participants preventing the further uptake and implementation of CPAMS. CPAMS non-providers are willing to provide CPAMS; the main factor preventing this is availability of contracts. Conclusions Overall, pharmacists have favourable experiences of and attitudes towards CPAMS and strongly supported its wider implementation. Promoting the benefits and addressing the barriers highlighted in this study may lead to wider implementation of CPAMS.

[Pharmacist-led anticoagulation monitoring can significantly improve the effectiveness and safety of warfarin for patients during hospitalization]

OBJECTIVE

To investigate the role of pharmacist-led anticoagulation monitoring service for warfarin anticoagulation therapy in patients during hospitalization.

METHODS

We retrospectively analyzed the data of 421 patients receiving warfarin anticoagulation therapy during hospitalization between April, 2016 and December, 2017. Of these patients, 316 received daily pharmacist-led anticoagulation monitoring service including checking the patients' International Normalized Ratio (INR) and other pertinent laboratory test results and reviewing medication changes and the patients' clinical status (monitoring group); the other 105 patients receiving warfarin anticoagulation therapy without pharmaceutical care served as the control group. The data including compliance rate of anticoagulant indicators, incidence and rate of prompt management of INR alert, thrombosis and bleeding events during hospitalization were analyzed among these patients.

RESULTS

Compared with the control patients, the patients in the monitoring group showed a significantly higher percentage time within target INR range [(73.20±9.46)% vs (46.32±17.11)%, P < 0.001] and a higher qualified rate of INR before discharge (98.42% vs 60.95%, P < 0.001) as well as a higher proper INR-monitoring frequency (97.15% vs 66.67%, P < 0.001). The patients in the monitoring group showed a significantly lower incidence of INR alert than the control patients (8.23% vs 20.00%, P < 0.001) with also a much higher rate of prompt management (96.15% vs 33.33%). The two groups had similar incidences of clinical events except that the control group reported a higher incidence of minor bleeding episodes (9.52% vs 2.53%, P=0.005).

CONCLUSIONS

Pharmacist-led anticoagulation monitoring service can significantly improve the effectiveness and safety of warfarin anticoagulation therapy for patients during hospitalization.

Cultural Sensitivity and Global Pharmacy Engagement in Asia: China, Japan, South Korea, and Taiwan

Interest in global engagement among schools and colleges of pharmacy in the United States and Asian countries is growing. To develop fruitful relationships and engage in mutually enriching experiences, the cultural aspects of these countries need to be understood and respected. The aim of this paper is to facilitate culturally sensitive interactions between practitioners, faculty members, and students in the United States and those in Asian countries when they engage in health care practice and/or education. This paper introduces general information about China (including Macau and Hong Kong), Japan, South Korea, and Taiwan. Unique characteristics of the health care system and pharmacy education are described for each country. Stereotypes and misconceptions are discussed. Recommendations are included for initiating interactions and developing learning programs and scholarly collaborations while promoting culturally sensitive engagement. These recommendations are provided for US scholars, health care professionals, and students traveling to these countries as well as for those hosting visitors from these countries in the United States.

Improving warfarin therapy through implementation of a hospital-based pharmacist managed clinic in Jamaica

Background

Pharmacist managed warfarin clinics can improve the anticoagulation status of non-valvular patients. The first of such services was implemented at the Cornwall Regional Hospital in Jamaica in 2013.

Objectives

To assess the anticoagulation control of patients on warfarin therapy over six months in the pharmacist managed warfarin clinic at Cornwall Regional Hospital.

Methods

Retrospective docket review for the period January 2014 to December 2016 was done to include data of patients attending routine clinic appointments for at least six months. Age, gender, date of visit, indication for warfarin therapy, warfarin dose and International Normalized Ratio readings were extracted. Percentage time spent in therapeutic range (TTR) was calculated by month for six months using the Rosendaal linear interpolation method. Patient anticoagulation status was categorized as poor (TTR<40%), moderate (TTR=40-64%) or good (TTR≥65%) and anticoagulation status at three months and six months was compared.

Results

For the period of assessment, 52 patients were identified; the median age was 58 years and 36 patients were males. Deep vein thrombosis was the main indication for therapy (22 of 52) and median warfarin weekly dose ranged was 15.0-130 mg. At time of recruitment most of the patients were outside the target INR range (43 of 52). Within one month, the median TTR attained was 31% [IQR 62-10]. This significantly improved by second month to 60% [IQR 82-23] (p=0.001). By month three, the proportion of patients in good, moderate and poor anticoagulant status was 19/51, 15/51 and 17/51 respectively, which at six months changed to 23/51, 12/51. 16/51 respectively; thus, although coagulation status improved from month one to three, there was no significant improvement from month three to month six (p=0.31).

Conclusions

The pharmacist managed warfarin clinic monitoring services were successful in attaining TTRs >40% and sustaining these values over six months. The services should therefore be encouraged.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

BACKGROUND

Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants.

CONCLUSIONS

Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.