A Qualitative Systematic Review of Facilitators of and Barriers to Community Pharmacists-Led Anticoagulation Management Service

Objective:

To identify the facilitators of and barriers to the implementation of Community Pharmacists–Led Anticoagulation Management Services (CPAMS).

Data Sources:

MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL Register of Controlled Trials were searched from inception until August 20, 2021.

Study Selection and Data Extraction:

All abstracts proceeded to full-text review, which was completed by 2 reviewers. Data extraction was completed by a single reviewer and verified. Analysis was completed using best-fit framework synthesis.

Data Synthesis:

A total of 17 articles reporting on CPAMS from 6 jurisdictions were included: 2 Canadian provincial programs (Nova Scotia, Alberta), a national program (New Zealand), and 3 cities in the United Kingdom (Whittington and Brighton and Hove) and Australia (Sydney). Facilitators of CPAMS included convenience for patients, accessibility for patients, professional satisfaction for pharmacists, increased efficiency in anticoagulation management, improved outcomes, enhanced collaboration, and scalability. Barriers included perceived poor quality of care by patients, resistance by general practitioners, organizational limits, capping of the number of eligible patients, and cost.

Relevance to Patient Care and Clinical Practice:

The barriers and facilitators identified in this review will inform health policy makers on the implementation and improvement of CPAMS for patients and health care practitioners.

Conclusion and Relevance:

CPAMS has been implemented in 6 jurisdictions across 4 countries, with reported benefits and challenges. The programs were structurally similar in most jurisdictions, with minor variations in implementation. New anticoagulation management programs should consider adapting existing frameworks to local needs.

A randomized trial of restarting warfarin at maintenance versus loading doses following an elective procedure

Guidelines suggest restarting warfarin at known maintenance doses, although this may result in a delay to achieving therapeutic anticoagulation. As such, we compared the time to achieve an INR ≥ 2.0 between those restarting warfarin maintenance vs loading doses after transient interruption, and the impact on protein C, S and factor II levels. Patients requiring interruption of warfarin for elective procedures without hospitalization were randomized 1:1 to receive warfarin maintenance or loading doses (1.5 times the maintenance dose for 3 days followed by pre-procedural warfarin maintenance dosing). Protein C, S and Factor II were drawn at baseline (prior to warfarin interruption), 7 and 14 days after restarting warfarin. Among 19 patients randomized to maintenance and 20 to loading doses, nearly half in each group had mechanical heart valves with gastrointestinal endoscopic procedures most commonly performed (41%). The median number of days to reach an INR ≥ 2.0 was 7.8 days in the loading and 9.0 in the maintenance group (difference between medians 1.2 days, 95% CI -3.1 to 4.9; P = 0.19). Although levels of protein C, S and factor II were lower in the loading vs maintenance dose group, all remained above that of baseline. Warfarin resumption with loading doses shortened the time to achieve a therapeutic INR by a median of 1.2 days. Prompt warfarin dose escalation should be done in response to the INR. Protein C and S remained above pre-warfarin interruption levels, implying a lack of depletion with restarting warfarin.

Anticoagulation management by community pharmacists in New Zealand: an evaluation of a collaborative model in primary care

Objectives

Despite the introduction of new oral anticoagulants, vitamin K antagonists remain the mainstay of the prevention and treatment of thromboembolism. The advent of affordable point-of-care testing presents an opportunity for community pharmacists to provide anticoagulation management services, better utilizing their training, reducing the workload on medical practices and improving accessibility and convenience for patients. This study aimed to determine the effectiveness of anticoagulation management by community pharmacists.

Methods

All patients enrolled in a pilot programme for a community pharmacy anticoagulation management service using point-of-care international normalized ratio testing and computer-assisted dose adjustment were included in a follow-up study, including before–after comparison. Outcomes included time in therapeutic range (TTR), time above and below range, number and proportion of results outside efficacy and safety thresholds, and a comparison of care led by pharmacists and care led by a primary-care general practitioner (GP).

Key findings

A total of 693 patients were enrolled, predominantly males over 65 years of age with atrial fibrillation. The mean TTR was 78.6% (95% CI 49.3% to 100%). A subgroup analysis (n = 221) showed an increase in mean TTR from 61.8% under GP-led care to 78.5% under pharmacist-led care (P < 0.001), reflecting a reduction in the time above and, in particular, below the range. The mean TTR by pharmacy ranged from 71.4% to 84.1%. The median number of tests per month was not statistically different between GP- and pharmacist-led care.

Conclusions

Community-pharmacist-led anticoagulation care utilizing point-of-care testing and computerized decision support is safe and effective, resulting in significant improvements in TTR. Our results support wider adoption of this model of collaborative care.

A community pharmacist-led anticoagulation management service: attitudes towards a new collaborative model of care in New Zealand†

Objective

To examine attitudes towards a new collaborative pharmacy-based model of care for management of warfarin treatment in the community. As background to the study, the New Zealand health authorities are encouraging greater clinical involvement of community pharmacists.

Methods

Fifteen community pharmacies in New Zealand took part in a community pharmacist-led anticoagulation management service (CPAMS). Participants (patients, general practitioners, practice nurses, pharmacists) were surveyed on their views on accessibility, convenience, confidence in the service, impact on warfarin control, impact on workloads, effect on relationships and whether the service should be further implemented. A small number from each group was interviewed on the same topics.

Key findings

Patients reported improved access, convenience, a preference for capillary testing, and the immediacy of the test result and dose changes. They indicated that they had a better understanding of their health problems. While sample sizes were small, the majority of general practitioners and practice nurses felt there were positive benefits for patients (convenience) and themselves (time saved) and expressed confidence in pharmacists' ability to provide the service. There were some concerns about potential loss of involvement in patient management. Pharmacists reported high levels of satisfaction with better use of their clinical knowledge in direct patient care and that their relationships with both patients and health professionals had improved.

Conclusions

The new model of care was highly valued by patients and supported by primary care practitioners. Wider implementation of CPAMS was strongly supported. Pharmacists and general practitioners involved in CPAMS reported a pre-existing collaborative relationship, and this appears to be important in effective implementation.

Asleep at the Wheel: Pharmacy Practice Research Advocacy and Knowledge Translation by Canadian Pharmacy Organizations

Background:

The Blueprint for Pharmacy clearly articulates the need and imperative for pharmacy practice to move toward patient-centred care. Pharmacy professional organizations have a crucial role to play in this change, through leadership, communication and advocacy. This survey aimed to determine what knowledge translation (KT) activities were performed by Canadian pharmacy professional organizations in relation to a major pharmacy practice study.

Methods:

We sent a letter summarizing the findings and implications of the recently published hypertension trial, SCRIP- HTN, to the leaders of each pharmacy regulatory and advocacy body in Canada. Six months later, we followed up with these groups to inquire about KT activities that had been performed around the study findings.

Results:

Of the 22 organizations, 3 performed some type of KT activity. The major barrier to KT cited by the regulatory bodies was that it was not their job. The most common reason given by the advocacy bodies was that the study or its implications were not a priority. Other barriers included lack of time, lack of resources and political issues.

Conclusion:

KT and advocacy by our pharmacy professional organizations was practically nonexistent. This must change if we are to put into effect the vision of the Blueprint for Pharmacy for pharmacy practice change and optimal patient care.