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Eljilany I, El-Bardissy A, Nemir A, Elzouki AN, El Madhoun I, Al-Badriyeh D, Elewa H. Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey. J Thromb Thrombolysis 2021; 50:957-968. [PMID: 32307632 PMCID: PMC7575475 DOI: 10.1007/s11239-020-02111-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Arwa Nemir
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University & Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Ihab El Madhoun
- Department of Medicine, Al Wakra Hospital Hamad Medical Corporation, Al Wakra, Qatar.,Weill Cornell Medical College, Al Wakra, Qatar
| | | | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
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Fahmi AM, Mohamed A, Elewa H, Saad MO. Preemptive Dose Adjustment Effect on the Quality of Anticoagulation Management in Warfarin Patients With Drug Interactions: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2019; 25:1076029619872554. [PMID: 31482725 PMCID: PMC6829638 DOI: 10.1177/1076029619872554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One strategy to manage patients on warfarin starting an interacting drug is to increase
the frequency of monitoring. Another strategy is to adjust warfarin dose around the time
patient is started on an interacting medication, which is known as “preemptive warfarin
dose adjustment.” The main objective of this study is to compare preemptive to
nonpreemptive strategy and their impact on the quality of anticoagulation management. This
is a retrospective cohort study performed at the pharmacist-managed anticoagulation clinic
in a tertiary hospital in the State of Qatar. Over a 4-year period, 340 patients were
evaluated, and 58 warfarin–drug interaction encounters were identified. Mean age of the
patients was (57.7 ± 13.7), and 50% of them were females. Preemptive dose adjustment was
used in 17 (29.3%) cases. Incidence of out-of-target international normalized ratio (INR)
was statistically lower in the preemptive arm compared to the control group (41.2% [7/17]
vs 69.2% [27/39], P = .048). Incidence of extreme out-of-target INR was
numerically lower in the preemptive arm compared to the control but did not reach
statistical significance (11.8% [2/17] vs 29.3% [12/41], P = .139).
Change in frequency of INR monitoring was not different between the 2 groups. However,
overall frequency of INR monitoring after onset/discontinuation of interacting medication
increased compared to baseline (7 [9] vs 21 [16] days, P < .001).
Preemptive strategy was shown in our study to decrease incidence of the out-of-target INR
visits, although patients remained in need for close monitoring.
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Affiliation(s)
| | - Adham Mohamed
- 1 Al Wakra Hospital, Hamad Medical Corporation, Al Wakra, Qatar
| | - Hazem Elewa
- 2 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Manzoor BS, Bauman J, Shapiro NL, Stamos T, Galanter W, Nutescu EA. Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Beenish S. Manzoor
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
| | - Jerry Bauman
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Medicine, Section of Cardiology; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - Nancy L. Shapiro
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
| | - Thomas Stamos
- Department of Medicine, Section of Cardiology; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - William Galanter
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Medicine, Section of Academic Internal Medicine; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - Edith A. Nutescu
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
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Garwood CL. The future of anticoagulation management services: Ensuring and expanding patient access to pharmacists' care. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Candice L. Garwood
- Clinical Pharmacy Specialist, Harper University Hospital, Detroit Medical Center, Professor (Clinical), Eugene Applebaum College of Pharmacy and Health Sciences Wayne State University Detroit Michigan
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Manzoor BS, Cheng WH, Lee JC, Uppuluri EM, Nutescu EA. Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review. Ann Pharmacother 2017; 51:1122-1137. [PMID: 28735551 DOI: 10.1177/1060028017721241] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To perform a systematic review to evaluate the quality of warfarin anticoagulation control in outpatient pharmacist-managed anticoagulation services (PMAS) compared with routine medical care (RMC). DATA SOURCES MEDLINE, SCOPUS, EMBASE, IPA, CINAHL, and Cochrane CENTRAL, from inception to May 2017. Search terms employed: ("pharmacist-managed" OR "pharmacist-provided" OR "pharmacist-led" OR "pharmacist-directed") AND ("anticoagulation services" OR "anticoagulation clinic" OR "anticoagulation management" OR "anticoagulant care") AND ("quality of care" OR "outcomes" OR "bleeding" OR "thromboembolism" OR "mortality" OR "hospitalization" OR "length of stay" OR "emergency department visit" OR "cost" OR "patient satisfaction"). STUDY SELECTION AND DATA EXTRACTION Criteria used to identify selected articles: English language; original studies (comments, letters, reviews, systematic reviews, meta-analyses, editorials were excluded); warfarin use; outpatient setting; comparison group present; time in therapeutic range (TTR) included as a measure of quality of anticoagulant control; study design was not a case report. DATA SYNTHESIS Of 177 articles identified, 25 met inclusion criteria. Quality of anticoagulation control was better in the PMAS group compared with RMC in majority of the studies (N = 23 of 25, 92.0%). Clinical outcomes were also favorable in the PMAS group as evidenced by lower or equal risk of major bleeding (N = 10 of 12, 83.3%) or thromboembolic events (N = 9 of 10, 90.0%), and lower rates of hospitalization or emergency department visits (N = 9 of 9, 100%). When reported, PMAS have also resulted in cost-savings in all (N=6 of 6, 100%) of studies. CONCLUSIONS Compared with routine care, pharmacist-managed outpatient-based anticoagulation services attained better quality of anticoagulation control, lower bleeding and thromboembolic events, and resulted in lower health care utilization.
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Affiliation(s)
| | - Wei-Han Cheng
- 2 University of Southern California, Los Angeles, CA, USA
| | - James C Lee
- 1 University of Illinois at Chicago, Chicago, IL, USA
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Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA 2016; 316:2115-2125. [PMID: 27893129 PMCID: PMC6490178 DOI: 10.1001/jama.2016.16201] [Citation(s) in RCA: 432] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE The Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts. OBJECTIVE To describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006. DESIGN, SETTING, AND PARTICIPANTS Active, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. EXPOSURES Drugs implicated in ED visits. MAIN OUTCOMES AND MEASURES National weighted estimates of ED visits and subsequent hospitalizations for adverse drug events. RESULTS Based on data from 42 585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8%-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3%-5.6%). Among older adults (aged ≥65 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events. CONCLUSIONS AND RELEVANCE The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics.
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Affiliation(s)
- Nadine Shehab
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andrew I Geller
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
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Elewa H, Jalali F, Khudair N, Hassaballah N, Abdelsamad O, Mohammed S. Evaluation of pharmacist-based compared to doctor-based anticoagulation management in Qatar. J Eval Clin Pract 2016; 22:433-8. [PMID: 26766552 DOI: 10.1111/jep.12504] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES For over 60 years, warfarin has been the mainstay anticoagulant used in the outpatient setting for the prevention and treatment of a wide variety of thromboembolic clinical conditions. Guidelines recommend that health care providers managing oral anticoagulation therapy should do so in a systematic and coordinated fashion. Studies have shown that, when compared to traditional doctor-based anticoagulation management, pharmacist-managed anticoagulation services can improve patient outcomes. The first pharmacist-based anticoagulation clinic in Qatar was launched in 2013 at Alwakra Hospital. The primary objective of this research was to evaluate the impact of pharmacist versus doctor-based anticoagulation management on the percentage time under therapeutic INR (International Normalized Ratio; TTR), INR within therapeutic range and the extreme out of range INRs. METHOD A retrospective cohort study was designed to compare the anticoagulation control of pharmacist-based warfarin clinic to the usual doctor-care. RESULTS Data from 278 patients taking warfarin (78 managed at pharmacist and 200 at doctor-based clinic) were evaluated. Subjects followed at the pharmacist-based clinic had a superior TTR compared to those managed at the doctor-based clinic (81.8% vs. 69.8%, P < 0.001). Additionally, the percentage of visits within therapeutic range were significantly higher in the pharmacist's group compared to doctor's group (76.5% vs. 71.2%, P = 0.011). At the same time, percentage of visits with extreme subtherapeutic INR was reduced in the pharmacist-managed clinic (5.17% vs. 7.05%, P = 0.007) CONCLUSIONS: Our study indicates that pharmacist-based anticoagulation has better INR control when compared to the traditional anticoagulation management. Pharmacist-managed anticoagulation clinics should be considered and supported for warfarin management.
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Affiliation(s)
- Hazem Elewa
- College of Pharmacy, Qatar University, Doha, Qatar
| | | | - Nada Khudair
- College of Pharmacy, Qatar University, Doha, Qatar
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Abstracts from The American Telemedicine Association 2016 Annual Meeting and Trade Show. Telemed J E Health 2016; 22:A1-A102. [DOI: 10.1089/tmj.2016.29004-a.abstracts] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kovacs RJ, Flaker GC, Saxonhouse SJ, Doherty JU, Birtcher KK, Cuker A, Davidson BL, Giugliano RP, Granger CB, Jaffer AK, Mehta BH, Nutescu E, Williams KA. Practical Management of Anticoagulation in Patients With Atrial Fibrillation. J Am Coll Cardiol 2015; 65:1340-1360. [DOI: 10.1016/j.jacc.2015.01.049] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/21/2015] [Accepted: 01/29/2015] [Indexed: 11/16/2022]
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Baker WL. The Changing Face of Anticoagulation Management: An Improving Countenance. Pharmacotherapy 2013; 33:1133-5. [DOI: 10.1002/phar.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- William L. Baker
- University of Connecticut School of Pharmacy; Storrs Connecticut
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Nutescu EA, Bathija S, Sharp LK, Gerber BS, Schumock GT, Fitzgibbon ML. Anticoagulation patient self-monitoring in the United States: considerations for clinical practice adoption. Pharmacotherapy 2012; 31:1161-74. [PMID: 22122179 DOI: 10.1592/phco.31.12.1161] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Systematic management models such as anticoagulation clinics have emerged in order to optimize warfarin effectiveness and to minimize related complications. Most of these models are structured so that patients come to a clinic for in-person testing and evaluation, thus making this model of care difficult to access and time consuming for many patients. The emergence of portable instruments for measuring anticoagulant effect in capillary whole blood made it possible for patients receiving warfarin to self-monitor the effect of their anticoagulant therapy. Self-monitoring empowers patients, offers the advantage of more frequent monitoring, and increases patient convenience by allowing testing at home and avoiding the need for frequent laboratory and clinic visits. Self-monitoring can entail patient self-testing (PST) and/or patient self-management (PSM). Several studies have evaluated and shown the benefit of both PST and PSM models of care when compared with either routine medical care or anticoagulation clinic management of anticoagulation therapy. Self-monitoring (PSM and/or PST) of anticoagulation results in lower thromboembolic events, lower mortality, and no increase in major bleeding when compared with standard care. Despite favorable results and enhanced patient convenience, the adoption of self-monitoring into clinical practice in the United States has been limited, especially in higher risk, disadvantaged populations. Although the emergence of a multitude of novel oral anticoagulants will permit clinicians to better individualize anticoagulant therapy options by choosing the optimum regimen based on individual patient characteristics, it is also expected that traditional agents will continue to play a role in a significant subset of patients. For those patients treated with traditional anticoagulants such as warfarin, future models of care will entail patient-centered management such as PST and PSM. The incorporation of technology (i.e., Web-based expert systems) is expected to further improve the outcomes realized by PST and PSM. Further studies are needed to explore factors that influence the adoption of self-monitoring in the United States and to evaluate the feasibility and implementation in real-life clinical settings.
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Affiliation(s)
- Edith A Nutescu
- Department of Pharmacy Practice and Pharmacy Administration, University of Illinois at Chicago, Chicago, Illinois 60612-7230, USA.
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Gulseth MP, Wittkowsky AK, Fanikos J, Spinler SA, Dager WE, Nutescu EA. Dabigatran Etexilate in Clinical Practice: Confronting Challenges to Improve Safety and Effectiveness. Pharmacotherapy 2011; 31:1232-49. [DOI: 10.1592/phco.31.12.1232] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sisca TS. I'm Still Here: Reflections on 39 Years of Clinical Practice in a Community Hospital–Based Anticoagulation Service. Pharmacotherapy 2011; 31:1156-60. [DOI: 10.1592/phco.31.12.1156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hall D, Buchanan J, Helms B, Eberts M, Mark S, Manolis C, Peele P, Docimo A. Health Care Expenditures and Therapeutic Outcomes of a Pharmacist-Managed Anticoagulation Service versus Usual Medical Care. Pharmacotherapy 2011; 31:686-94. [DOI: 10.1592/phco.31.7.686] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Garwood CL, Bishja M, Smythe MA. An innovative elective course in anticoagulation management. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2010; 74:187. [PMID: 21436928 PMCID: PMC3058466 DOI: 10.5688/aj7410187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 08/09/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To develop and implement an elective pharmacy course in anticoagulation management and assess student learning. DESIGN Students participated in active-learning activities including evaluating a patient receiving outpatient or inpatient anticoagulation therapy, participating in a team project and presentation, and completing a "living with anticoagulation" assignment that included modeling both the health care provider's and the patient's role. ASSESSMENT A precourse and postcourse standardized examination on anticoagulation along with a short answer midterm and final examination were administered. Performance between precourse and postcourse examination improved by approximately 25%, and 90% of students scored ≥ 90% on the final examination. Reflective narratives provided support that students found the "living with anticoagulation" assignment a valuable learning experience which developed empathy towards patients. CONCLUSION An elective course in anticoagulation management that included multiple active-learning assignments was successful in increasing both students' knowledge and empathy.
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Affiliation(s)
- Candice L Garwood
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, USA
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