Describing the profile of patients on concurrent rifampin and warfarin therapy in western Kenya: a case series

Background

Rifampicin’s ability to induce hepatic enzymes is responsible for causing a clinically significant drug interaction with warfarin. Little data exists to guide clinicians on managing this interaction, especially in Sub-Saharan Africa where many patients are exposed to this combination due to a higher burden of tuberculosis.

Objective

The objective of the case series is to provide insight to practicing clinicians of the unique dynamics of this drug interaction in resource-constrained settings. The case series will provide details on commonly encountered scenarios and the dosage adjustments required to maintain a therapeutic INR.

Methods

A retrospective chart review was conducted of patients attending the Moi Teaching and Referral Hospital anticoagulation clinic in Eldoret, Kenya. Patients were included if they had a history of concurrent rifampicin and warfarin therapy and a minimum follow up of 2 months. Descriptive statistics were used to explain the demographic characteristics, time to therapeutic INR and average weekly warfarin dose. The inference on proportions test was conducted to compare the time in the therapeutic range (TTR) for patients on concurrent rifampicin to the rest of the patients not receiving rifampicin in the clinic.

Results

Of the 350 patient charts evaluated, 10 met the inclusion criteria. The median percentage increase of the weekly warfarin dose from baseline was 15.7 %. For the patients in this analysis, the median TTR was 47 %.

Discussion

Patients on concurrent therapy should be rigorously monitored with regular INR checks and warfarin dosage adjustments. Empiric dosage adjustments of warfarin should be avoided but patient characteristics can aid in understanding the alterations seen in INR.

Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya

BACKGROUND

It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease.

OBJECTIVE

To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings.

METHODS

A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon's rank sum analyses were used to establish predictors of TTR.

RESULTS

For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow-up of < 120 days were associated with having a lower TTR (P < 0.05).

CONCLUSIONS

The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.

Marketing the GP/specialist referral system: an opportunity for the future

Despite the predictions of some gloom casters, there is a strong economic future for dentistry. One of the ways to ensure this strength is to develop an enhanced integrated approach to the general practitioner/specialist referral system. This requires a planned marketing technique that draws the two practices--GP and specialist--into an alliance of greater understanding.

Pencil and paper: the simple solution to getting the numbers you need to effectively manage your practice

Once you have mastered the basics by going through the monitoring exercise once or twice, you will find it takes little time and effort to start finding out just where your practice stands. You only solve a problem after you have found out that there is one and you might find that this simple monitoring exercise shows you areas of your practice where a little attention from you will pay big dividends. Monitoring is like a fine wine: it improves with age. As you begin to compile more and more months of data, you will be able to start comparing this month's performance with last month's, or this quarter with last quarter, this year with last year. One of the most useful things monitoring will do for you is to allow you to compare your practice's performance with that of other practices. Averages, norms, and performance survey results are to be found in a range of practice management publications. Using your monitoring information in this comparative way helps you to identify those areas in your practice management that are holding you back from achieving your true potential. This lets you focus your management time and effort on the truly important issues, which, when solved, will help you turn your practice into a less stressful, more enjoyable, and more profitable place to work.

Beyond the bells and whistles. What high technology really delivers

There's something seductive about technology. It's exciting, bold, fresh and constantly reinventing itself. This allure is hard to resist, as last year's Windows '95 hype can well attest. In a time-starved society in which automobile drivers become impatient sitting at red lights, it's noteworthy that many spent one night last year lined up in front of retail stores about to release Bill Gates' much ballyhooed software.

Creating value for your staff

Your staff are the agents of success in your practice. It is through their collective, quality efforts that your vision comes to fruition. Treat this investment in human resources with care and nourishment, and you'll be well on your way to establishing a thriving dental practice--one which can claim that not only its patients, but its staff as well, are its biggest fans.

Managing emergency patients

Whether it's a new or existing patient who contacts your office about a dental emergency, you and your team have to handle the call with the utmost sensitivity. These patients may be in pain. They need to be treated at a practice that knows how to manage the situation, allowing them to feel relaxed and confident about the impending care. Many new patients find that visiting a dental practice is often an unfamiliar, anxiety-provoking experience. But if you've developed a strong, effective protocol for dealing with dental emergencies, these new patients may ultimately overcome their hesitancy and become enthusiastic patients. It's all about reading and attending to their unique needs.

Time out

Earlier in this article, I emphasized that leisure and time away from work are not only important in and of themselves, but that they're important to our work. Again, I draw from my own recent experience of a few days vacation in Florida. The "time out" didn't just allow me to relax, it also gave me a healthy perspective on my work and a freshness in pursuing my goals, something that's very difficult to achieve when you're fully immersed in day to day business matters. Dr. Lagstein underscores this point: "I've recently begun using my time away from the office as a direct adjunct to the practice. It seems that my most creative thinking and planning for the practice occurs when I'm furthest from the operatory," he says. "My outlook is enhanced in a way that can't be emulated when I'm consumed with the day-to-day challenges of dentistry. And yes, this has a direct impact on my production; but contrary to what most people would expect, it has increased--not detracted from--my annual net revenue." Dentists who are already achieving this balance should be applauded, but for those who are not, I encourage you to find the way to start doing so. As Bruce O'Hara rightly says, "Prosperity/leisure is not an either/or choice: in the 1990s we must create the means to have them both, or we will wind up with neither."

Managing anxious patients

During a 1993 CDA-sponsored seminar, New and Improved: the Canadian Dental Consumer in the '90s, the lecturer, Mark Sarner of Manifest Communications, indicated that there was "cause for celebration." Why? Fewer people than ever believe that dental visits equal pain. A recent survey revealed that 58 per cent of the respondents disagreed with the statement, "When I think of going to the dentist, I think of pain." Through sensitivity, compassion and ever-advancing pain control, dental teams can rise to the challenge of further eliminating the perception that dentistry and pain go hand in hand, and thereby reduce dental fears. If this is done successfully, the profession could obtain future survey results in which a full 100 per cent of respondents disagree with the statement, "When I think of going to the dentist, I think of pain." Now that would be cause for some serious celebration.

Meeting the needs of special-needs patients

In today's society, the trend is toward massive de-institutionalization of individuals with special needs. With the growth of community-based facilities and healthcare, dentists need to embrace the challenge of meeting the oral health needs of special-needs patients. To do so, and establish a trust relationship with these patients, they will require training, education and, above all, compassion. Through accessibility, the provision of care and positive attitudes, the dental profession can profoundly assist in improving the quality of life of special-needs patients.

Re-engineering the dental practice

Although this is the last in our three-part series on re-engineering, it's unlikely to be the last word you'll hear on the subject. The organizations that experience continued success as we approach the next millennium will be those that can adapt to the ever fluid economy by making core--not cosmetic--changes. And it is the concept and implementation of re-engineering that will provide the model for doing just that.

Achieving success: moving beyond the comfort level

Understanding the stages of growth, saturation and transition is the first step to setting meaningful career goals. While this concept is fairly new in dentistry, it is not new in other commercial enterprises. Business managers and owners have known for decades that growth stagnates after a period of time. At that point, a new infusion of energy and a reformation of the business's objectives and methods are needed to launch forward into the next phase of growth. Transition management in dentistry represents periods of growth that are followed by saturation and a comparatively rapid changeover to a new practice form. Saturation occurs when the clinical capacity of a practice is exceeded by the needs of a growing patient base. The key transitions in the career of a dentist are those from school to practising, and practising to retirement. A great number of dentists (due to low motivation, the comfort level or poor management skills) never reach the saturation point during their practising career. For these dentists, starting out and retirement are the only transitions that will ever apply to them. Dentists evaluating transition options must first identify which career stage they belong to since their objectives will be different at each stage. Dentists in the growth phase should focus on practice management and achieving saturation before attempting a transition. Since transitions like start-up, retirement, partnerships, associateships and buy-ins have pivotal roles in the life cycle of a practice, transitions must be managed carefully to achieve successful results.(ABSTRACT TRUNCATED AT 250 WORDS)

The do's and don'ts of marketing

Marketing is a tough area for most dentists. They either reject it altogether (an attitude that is bound to go the way of the dinosaurs because of sheer economics) or they accept its role in principal but aren't sure about the choreography for the marketing moves. What's important for dentists who embrace marketing is that their actions are well thought out, planned and executed. Because the fallout from inappropriate or ineffectual marketing can be bottomless. The idea (a variation of that old adage) is to please most of the people most of the time, as in the cited rose example above. (Yes, Abby sided with the wife.)

Patient newsletters: the debate continues

Producing a patient newsletter is a worthwhile venture if you're doing it for the right reasons. As one component of an overall internal marketing strategy, it demonstrates to patients that you are a concerned caregiver, not only during their visits to your practice but in between those visits. If it's a professional-looking publication with quality content and visuals, it will likely be appreciated by your patients. And as you well know, the dental profession is certainly not suffering from a surplus of appreciation.

Quality service and a personal touch: redefining the "M" word

Like it or not, dentistry is a service that patients (the consumers) may choose to reject. It's up to individual dentists to convince patients that their oral health should rank as a top priority. To achieve this goal, dental professionals must make a commitment to provide quality and personalized service. And this begins by developing and implementing a marketing strategy that defines and tracks patients' seemingly elusive needs.

The new patient experience putting your best foot forward

By implementing a consistent new patient experience, your practice will have put its best foot forward. It's the first step toward achieving your next challenge: turning new patients into established patients. This requires you to provide quality dentistry and a high level of service during each and every patient visit.