Moving anticoagulation initiation and monitoring services into the community: evaluation of the Brighton and hove community pharmacy service

Pharmacy-Led Management of Atrial Fibrillation: Improving Treatment Adherence and Patient Outcomes

The world's population is ageing, with the number of those over 60 years expected to represent a fifth of the total population by 2050. Increases in chronic long-term health conditions (LTCs) associated with ageing, and requiring regular but often avoidable medical intervention, are pressurising already overloaded, health and social care systems. Atrial fibrillation (AF) is an LTC, which is most frequently diagnosed in the elderly. An often, asymptomatic condition, AF is associated with a 3- to 5-fold increased risk of severe ischemic stroke. Stroke prevention, with risk-stratified oral anticoagulants (OACs) is the standard recommended care for patients with AF. Stroke avoidance is, however, dependent on persistent adherence to OAC medication, with an adherence rate of >80% considered necessary to achieve optimal health outcomes. Suboptimal adherence to OACs is common, with a third of all AF patients not taking their medication as prescribed. This combined with the short half-life of OACs can result in poor clinical outcomes for patients. Policy makers now consider improving adherence to prescribed medicines for LTCs, a public health priority, to ensure better health outcomes for patients, whilst minimising unnecessary health system costs. Prescribing medicines to treat LTCs, such as AF, is not enough, particularly when the patient may not experience any measurable benefit to the treatment and may instead, experience medication-associated adverse events, including a risk of bleeding. Pharmacists who are experts in medicines management are ideally placed to support medication adherence, to educate, and to improve health outcomes for patients with AF. In this review, I will consider the evidence for poor medication adherence in LTCs and in particular adherence to OACs in patients with AF and highlight the role that pharmacists can play in ensuring optimal adherence and showcase pharmacist-led interventions that effectively address this problem.

Comparison of medical documentation between pharmacist-led anticoagulation clinics and physician-led anticoagulation clinics: A retrospective study

Background and objectives

High-quality documentation is critical in medical settings for providing safe patient care. This study was done with the objective of assessing the standard of medical records in anticoagulation clinics and investigating the distinctions between notes written by pharmacists and physicians.

Methods

A retrospective cross-sectional analysis of data from electronic health records (EHRs) was performed on patients who received anticoagulation and were observed at anticoagulation clinics from October to December 2020. Patients were monitored in two anticoagulation clinics, one administered by pharmacists and the other by physicians. The quality of the documentation was assessed using a score, and the note was assigned one of five categories according to its score: very good, good, average, poor, and very poor. The data was analyzed using Stata/SE 13.1. P value<0.05 was considered significant in all analytical tests.

Results

A total of 331 patients were included. While 160 patients (48.3%) were followed by the physician-led clinic, 171 (51.6%) were by the pharmacist-led clinic. The average age of the patients was 54 ± 15. 60.73% of them were female, and 90.3% of them were Saudi nationals. Warfarin was the most widely used anticoagulant (70%), followed by rivaroxaban (15.7%). Compared to physicians, pharmacists demonstrated very strong documentation (54% vs. 18%). The examination of the variables considered in the study revealed that physicians had significantly less drug-drug interaction documentation (17 vs. 71 times) or drug-food interaction documentation (23 vs. 71 times) than pharmacists. In terms of follow-up frequency, pharmacists were found to adhere to the clinic protocol (150 times) more frequently than physicians (104 times). However, there was no significant difference in therapeutic plan documentation between the two groups. (p = 0.416).

Conclusion

Pharmacists were more comprehensive in their documentation than physicians in anticoagulation clinics. Unified clinic documentation can ensure consistent documentation within EHRs across all disciplines.

A regional anticoagulation program improves safety and outcomes for both children and adults

BACKGROUND

Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program.

AIMS

The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications).

METHODS

Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed.

RESULTS

The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%.

CONCLUSIONS

In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.

Challenges of Anticoagulation Management Service and Need of Establishing Pharmacist-Led Anticoagulation Clinic in Tertiary Care Teaching Hospital, Ethiopia: A Qualitative Study

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.

The patient's medication access journey: a conceptual framework focused beyond adherence

BACKGROUND: It is well known that medication accessibility reduces morbidity and mortality and increases health-related quality of life; however, despite efforts to improve health care access, many Americans still face challenges in accessing medications. Several health care access and utilization conceptual frameworks have been created and used for decades to illustrate key relationships and interdependencies between elements of the system. However, none of these frameworks have focused exclusively on medication access and associated factors. Medication access is a complex, multidimensional issue that must consider not only patient-specific challenges, but also health system limitations, among others. A better understanding of medication access, beyond the proxy marker of adherence, is needed to identify opportunities to improve accessibility. OBJECTIVE: To develop a conceptual framework that defines a patient's medication access journey and characterizes barriers frequently encountered while seeking medication access. METHODS: A multistakeholder roundtable composed of 15 experts from across the health care continuum was convened in 2018 by the Pharmacy Quality Alliance to develop a conceptual framework for medication access. The roundtable participants were convened through in-person and telephonic meetings. To inform their work, 2 literature reviews and an environmental scan were conducted to identify medication access barriers, interventions affecting medication access, and medication access quality measures. RESULTS: The resulting framework included 7 nodes that represent the major access points encountered by patients when attempting to access medications: perceived need, help seeking, encounter, prescribing, prescription adjudication, prescription dispensing, and adherence. Also, 18 barriers were identified. Patient health literacy, cost, insurance, and organizational health literacy were predominant barriers across multiple nodes. CONCLUSIONS: The framework that was developed provides a patient-focused, holistic view of medication access, incorporating access nodes and corresponding barriers. It also provides a structure to consider key opportunities for interventions and measurement to address medication access challenges. DISCLOSURES: This study was conducted with grant support from the National Pharmaceutical Council, which served as a collaborator in the study. Westrich is employed by the National Pharmaceutical Council. Nelson is employed by the Pharmacy Quality Alliance, which was contracted to conduct this study. Pickering, Campbell, and Holland were employed by the Pharmacy Quality Alliance at the time of this study. This research was presented as a professional poster at the American Public Health Association Annual Meeting in October 2019, Philadelphia, PA.

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.

Drive-through Anticoagulation Clinic During The COVID-19 Pandemic

An innovative approach to anticoagulation management during the COVID-19 pandemic was used at our center that allowed patients to stay in their vehicle while our anticoagulation advanced practice registered nurse obtained blood for point-of-care international normalized ratio (INR) testing while education and counseling were completed. A significant improvement in the median percentage of INR within the therapeutic range was observed among the patients who used the drive-through clinic. A small group of patients improved compliance to anticoagulation monitoring. Clinical care models, such as this clinic approach may improve patient compliance and adherence to anticoagulation beyond the pandemic needs.

A De Novo Pharmacist-Family Physician Collaboration Model in a Family Medicine Clinic in Alberta, Canada

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists’ education and clinical experience gained trust from the family physician. These, coupled with the family physician’s previous positive experience working with pharmacists made the collaboration achievable.

Patient Perspectives on Factors Affecting Direct Oral Anticoagulant Use for Stroke Prevention in Atrial Fibrillation

INTRODUCTION

Oral anticoagulant therapy choices for patients with atrial fibrillation (AF) expanded in the last decade with the introduction of direct oral anticoagulants (DOAC). However, the implementation of DOACs was slow and varied across different health economies in England. There is limited evidence on the patient role in the uptake of new medicines, including DOACs, apart from considering their demographic and clinical characteristics. Hence, this study aimed to address the gap by exploring the view of patients with AF on factors affecting DOAC use.

METHODS

A qualitative study using semi-structured interviews was conducted in three health economies in the North of England. Adult patients (>18 years) diagnosed with non-valvular AF, prescribed an oral anticoagulant (vitamin K antagonist or DOAC), and able to give written consent were recruited. Data were collected between August 2018 and April 2019. Audio recorded interviews were transcribed verbatim and analyzed using the framework method.

RESULTS

Four themes with eleven subthemes discussed identified factors affecting the use of DOACs. They were linked to limited healthcare financial and workforce resources, patient involvement in decision-making, patient knowledge about DOACs, safety concerns about oral anticoagulants, and oral anticoagulant therapy impact on patients' daily lives. Lack of a) opportunities to voice patient preferences and b) information on available therapy options resulted in some patients experiencing difficulties with the prescribed therapy. This was reported to cause negative impact on their daily lives, adherence, and overall satisfaction with the therapy.

CONCLUSION

Greater patient involvement in decision-making could prevent and resolve difficulties encountered by some patients and potentially improve outcomes plus increase the uptake of DOACs.

COPD Management in Community Pharmacy Results in Improved Inhaler Use, Immunization Rate, COPD Action Plan Ownership, COPD Knowledge, and Reductions in Exacerbation Rates

Purpose

To evaluate the effectiveness of a pilot community pharmacy care model for patients with chronic obstructive pulmonary disease (COPD) to improve: 1) inhaler technique; 2) medication adherence; and 3) uptake of non-pharmacological treatment and prevention activities.

Patients and Methods

Forty "host" pharmacies in Sydney were invited to recruit eligible patients and to provide a counselling room/area in their pharmacy for service provision. Eligible patients were referred to two "consultant" pharmacists, specifically trained to deliver a specialized pharmacy COPD service which involved 3 in-pharmacy visits and 2 follow-up phone calls over a 6-month period. The service consisted of 1) inhaler technique assessment; 2) medication adherence assessment; and 3) referrals to the patient's general practitioner (GP) to facilitate the uptake of non-pharmacological resources as well as to review COPD medications/devices, as required. Pre-post analyses were conducted using paired Student's t-test and Wilcoxon Signed Rank Test for independent variables and chi-squared tests for proportional data.

Results

Nine "host" pharmacies recruited 40 patients, of whom 37 completed the baseline Visit and 27 completed all Visits. A total of 270 interventions were provided by the "consultant" pharmacists with most provided at Visit 1 (176). The most common interventions were addressing patient gaps in COPD knowledge and inhaler technique. A total of 119 referrals were made to GPs for various reasons, the most common being for a COPD action plan, pulmonary rehabilitation, or pneumonia vaccination. There were significant improvements pre-post intervention in inhaler use competence, COPD knowledge, immunization rate for pneumonia, exacerbation rate and COPD plan ownership.

Conclusion

In this pilot study, the specialized pharmacy-based COPD care model delivered by "consultant" pharmacists in community pharmacies provided significant health benefits for patients. Further research is needed to assess the model's effectiveness in a larger population as well as when measured against standard care.

Outpatient treatment of pulmonary embolism

Over the past decade there has been an increasing trend to manage many conditions traditionally treated during a hospital admission as outpatients. Evidence is increasing to support this approach in patients with pulmonary embolism (PE). In this article, we review the current status of outpatient management of confirmed PE and present a pragmatic approach for clinical healthcare settings.

Outpatient management of pulmonary embolism should be considered in all eligible patients to prevent unnecessary hospital admissions and improve quality of carehttps://bit.ly/3mo5TX7

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.

Evaluation of patients' knowledge about oral anticoagulant medicines and use of alert cards by community pharmacists

Background Anticoagulants continue to pose high risk of harm to patients despite the discovery of novel direct-acting oral anticoagulant agents that require less monitoring than warfarin. Objective To evaluate patients’ knowledge about their oral anticoagulants and the potential role for community pharmacists in optimising safety. Setting Community pharmacies in England. Methods An online survey-based evaluation conducted over a 5-month period to ascertain patients’ knowledge, use of anticoagulant alert cards, compliance with national monitoring requirements for warfarin, and frequency and nature of community pharmacist involvement in optimisation. Differences between patients on direct-acting oral anticoagulant agents and warfarin were assessed using Chi squared tests. Main outcome measure Patients’ knowledge and use of anticoagulant alert cards. Results A total of 1515 pharmacies participated. Of 22,624 patients, 97% knew that they were taking anticoagulants; 20% had alert cards with them at time of dispensing; 17% had no card and 10% refuted their usefulness. Patients on warfarin were more aware of interactions with over-the-counter or herbal medicines than those on direct-acting oral anticoagulant agents. Of the patients on warfarin, 82% confirmed monitoring in the previous 12 weeks in accordance with national standards, with the international normalised ratio value known for 76%. Pharmacists intervened in a fifth of the patients to issue an alert card, contact the general practitioner for a change in the prescription or due to interacting medicines. Conclusion Patients had reasonable knowledge of their anticoagulation therapy, but areas for improvement were identified. Community pharmacists are well placed to optimise the safe use of anticoagulants.

Anticoagulation Control of Warfarin in Pharmacist-Led Clinics Versus Physician-Led Clinics: A Prospective Observational Study

Purpose

Warfarin is an affordable drug used for numerous indications, and still a favorable choice for patients with a history of bleeding from direct oral anticoagulants or presence of valvular heart diseases. However, warfarin requires regular international normalized ratio (INR) monitoring for safety and efficacy. Warfarin’s efficacy and safety is correlated with actual time spent within the therapeutic INR. Time in therapeutic range (TTR) is an estimate that measures the percentage of actual time spent within the therapeutic INR. Our aim was to investigate differences in anticoagulation control of warfarin using TTR between pharmacists and other health-care providers.

Methods

This prospective observational study was conducted in an ambulatory-care setting of a tertiary hospital to compare anticoagulation management using TTR between clinics run by pharmacists versus other health-care providers.

Results

A total of 62 patients were enrolled: 33 in the pharmacist-led clinic and 29 in the physician-led clinic. TTR levels were statistically higher among patients in the pharmacist-led clinic than than the physician-led clinic (87.27%±3.82% and 52.48%±5.49%, respectively; p<0.001). For 27 patients followed retrospectively by physicians and prospectively by clinical pharmacists, TTR was statistically higher during clinical pharmacists’ care (91.70%±2.93% versus 61.39%±5.11%, respectively; p<0.001). During the study, approximately 82% of patients reached their target INR in the pharmacist-led clinic compared to 24% in the physician-led clinic.

Conclusion

The findings of our study found that patients followed in the pharmacist-led clinic had higher TTR levels than those followed in the physician-led clinic.

Patient satisfaction with community pharmacist-led anticoagulation management services and its relationship with patient characteristics in New Zealand

Background Community pharmacist-led anticoagulation management service (CPAMS) offers international normalised ratio point-of-care testing of warfarin in a community pharmacy setting. It has now expanded with 7,344 patients enrolled in the service across 164 pharmacies in New Zealand. The clinical benefit of CPAMS has been shown to be superior, but patient satisfaction with the service has not been fully explored. Objective To develop a questionnaire to assess patient satisfaction with CPAMS and evaluate its psychometric properties. Additionally, to determine the level of patient satisfaction with CPAMS and identify determinants of satisfaction with CPAMS. Settings 1071 patients enrolled in CPAMS across New Zealand invited to take part in the study. Main outcome measure Satisfaction with CPAMS service. Methods Adult patients taking warfarin and currently enrolled in CPAMS were recruited through the national international normalised ratio online system and invited to complete a 36-item survey assessing satisfaction with CPAMS. To identify the most important dimensions of patient satisfaction, exploratory factor analysis was used. Multivariate linear regression models were used to examine the effect of independent variables on patient satisfaction. Results A total of 305 patients completed the survey. The mean overall satisfaction score was 94.5% ± 13.1 out of maximum possible points. Five dimensions of patient satisfaction were identified by factor analysis: patient-centred communication, confidence in pharmacist competence, patient-pharmacist relationship, confidence in CPAMS, and pharmacy environment. Being older and more frequent visits to a pharmacy were positively associated with patient satisfaction. Living more than 1 km away from a pharmacy, and 'poor' self-perceived health status were negative predictors of patient satisfaction. Being Māori or of other ethnic minority was also associated with lower satisfaction scores, exploratory analysis suggests patient-pharmacist relationship is an important driver of these differences. Conclusions The high level of patient satisfaction further supports the effectiveness of CPAMS as a delivery model. Patient satisfaction is affected by age, frequency of pharmacy visits, ethnicity, travel distance to pharmacy, and perceived health status. Policy makers and practitioners should consider the characteristics of patients with low levels of satisfaction to improve and enhance CPAMS engagement.

The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility

Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.

Systematic review to inform the development of a community pharmacy-based intervention for people affected by dementia

OBJECTIVES

People living with dementia (PWD) frequently receive medicine regularly from their community pharmacy, thus providing an opportunity to address either directly or through a carer any unmet medicine-related needs. The aim of this systematic review was to identify, describe, and evaluate the quality of the research for dementia-specific pharmacy-based interventions with potential for delivery through community pharmacy. This would inform the design of future services and associated trials.

KEY FINDINGS

The systematic review process identified 29 studies. Interventions were categorised as medication review, targeted medicine intervention, education, memory screening and miscellaneous. Five studies were set in community pharmacy. Interventions frequently targeted antipsychotics, benzodiazepines and anticholinergic medication. Twenty interventions were medicine-related. Eighteen studies were categorised as 'very low' quality, often due to small sample size.

SUMMARY

The review identified a range of interventions, which could be delivered through community pharmacy, and potentially benefit PWD. Developing appropriate and efficient training and working in multi-disciplinary teams were identified as necessary for effectiveness. Further research is needed to identify which service elements are likely to be acceptable to both patients and practitioners as well as the barriers and enablers to their implementation.

One-year risks of stroke and mortality in patients with atrial fibrillation from different clinical settings: The Gulf SAFE registry and Darlington AF registry

BACKGROUND

Differences exist in oral anticoagulation (OAC) use between different populations with atrial fibrillation (AF), which may be associated with varying outcomes.

PURPOSE

We aimed to provide patient level comparisons of two cohorts of patients with AF, from the United Kingdom (UK) and Middle East (ME).

METHODS

The clinical characteristics, prescription of OAC, one-year risk of stroke and mortality were compared between individual patients with AF included into the Darlington AF registry (UK, n = 2258) and the Gulf SAFE (Survey of atrial fibrillation events) registry (ME, n = 1740).

RESULTS

A high percentage of patients from the Darlington registry were candidates for OAC (i.e., CHA₂DS₂-VASc score ≥2 in males or ≥3 in females; 82.0% in Darlington and 57.1% in Gulf SAFE). OAC use was suboptimal (52.0% in Darlington vs 58.4% in Gulf SAFE). One-year rates of stroke and mortality were high in both populations, especially in those with CHA₂DS₂-VASc score ≥2 in males and ≥3 in females (Darlington vs. Gulf SAFE: 3.51% vs. 5.63 for stroke; 11.4% vs. 16.8% for mortality). On multivariate analyses, female sex and previous stroke were independently associated with stroke events; while elderly age, female sex, vascular disease and heart failure were independent risk factors for mortality (all p < 0.05). Patients from Gulf SAFE registry had higher risk of stroke (odds ratio, 2.18 [1.47-3.23]) and mortality (odds ratio, 1.67 [1.31-2.14]) compared with those from Darlington registry. The CHA₂DS₂-VASc score showed good discrimination in predicting one-year risk of stroke (area under curve, 0.71 [0.65-0.76] in non-anticoagulated patients) and mortality (area under curve, 0.70 [0.68-0.72]) in the whole study population, as well as in Darlington or Gulf SAFE registry separately.

CONCLUSIONS

Stroke prevention was generally suboptimal in patient cohorts from the two registries, which was associated with high one-year risks of stroke and mortality, particularly so among patients from the Gulf SAFE registry. The higher risks for stroke and mortality in AF patients from the Gulf SAFE registry (compared to a UK cohort) merit further implementation of cardiovascular prevention strategies.

Patient Education on Oral Anticoagulation

Given the potential harm associated with anticoagulant use, patient education is often provided as a standard of care and emphasized across healthcare settings. Effective anticoagulation education involves face-to-face interaction with a trained professional who ensures that the patient understands the risks involved, the precautions that should be taken, and the need for regular monitoring. The teaching should be tailored to each patient, accompanied with written resources and utilize the teach-back method. It can be incorporated in a variety of pharmacy practice settings, including in ambulatory care clinics, hospitals, and community pharmacies.