Effectiveness of pharmacist‐participated warfarin therapy management: a systematic review and meta‐analysis

Abstract

To cite this article: Saokaew S, Permsuwan U, Chaiyakunapruk N, Nathisuwan S, Sukonthasarn A. Effectiveness of pharmacist-participated warfarin therapy management: a systematic review and meta-analysis. J Thromb Haemost 2010; 8: 2418-27.Summary. Objective: Although pharmacist-participated warfarin therapy management (PWTM) has been accepted and implemented in various parts of the world, the evidence demonstrating the effects of PWTM compared with usual care on clinical outcomes is lacking. We performed a systematic review and meta-analysis to compare the effects of PWTM with usual care on bleeding and thromboembolic outcomes. Methods: We searched MEDLINE, SCOPUS, EMBASE, IPA, CINAHL, Cochrane CENTRAL, Thai Index Medicus and Thai Medical Index, and reference lists of studies, without language restriction. Databases were searched from their inception to July 2009. The studies using warfarin as an anticoagulant with sufficient data for compilation of 2 · 2 tables were included. Both randomized controlled trials (RCTs) and non-RCTs were considered. Two authors independently reviewed each study, assigned quality scores and extracted data for all outcomes using a standardized form. Pooled effect estimates (risk ratio; RR) were obtained using a random effects model. Result: Of 661 articles identified, 24 studies with 728,377 patients were included. In the random-effects meta-analysis of RCTs, the PWTM group had statistically significant effects on the prevention of total bleeding [RR, 0.51; 95% confidence interval (CI), 0.28-0.94]. However, the effects on major bleeding (RR, 0.64; 95% CI, 0.18-2.36), thromboembolic events (RR, 0.79; 95% CI, 0.33-1.93), all-cause mortality (RR, 0.93; 95% CI, 0.41-2.13) and warfarin-related mortality (RR, 0.65; 95% CI, 0.18-2.42) were not significant. Conclusion: PharmacistÕs participation in the management of warfarin therapy significantly reduces total bleeding, with a non-significant trend towards decreases in other warfarin-related complications.

Effectiveness of Pharmacist-led Anticoagulation Management on Clinical Outcomes: A Systematic Review and Meta-Analysis

“…The mortality was no significant between pharmacist-led anticoagulation management and other management models in our meta-analysis which was consistent with two former studies (16,17). Neither the warfarin-related mortality was no significant between pharmacist-participated warfarin therapy management and usual care from RCT (RR:0.65, 95%CI:0.18-2.42, p=0.524) and non-RCT (RR:0.77, 95%CI: 0.39-1.53, p=0.459) analysis (16).…”

“…And we were inclined to believe that pharmacist-led anticoagulation management decreased the risk of thrombosis events. Non-randomized controlled trails (quasi-experimental studies and cohort studies) analysis of Saokaew et al study supported that significant reduction of thrombosis events in pharmacist-participated warfarin therapy management group without conspicuous heterogeneity which was in line with our study (16).…”

“…Due to risk of bias in RCTs and imprecision of RCTs and observational studies, our pooled results provided low to very low evidence according to GRADE guidelines (20). On the contrary, Saokaew et al found that pharmacist-participated warfarin-therapy management was significantly associated with 51% reduction major bleedings compared with usual care (RR: 0.49, 95%CI:0.26-.093, p=0.030) with a medium level of heterogeneity (I 2 =46.7%, p=0.044) (16). Imparity of the definition of haemorrhage events that derived from included studies could lead to different results, especially the definition of major haemorrhage events.…”

“…Neither the warfarin-related mortality was no significant between pharmacist-participated warfarin therapy management and usual care from RCT (RR:0.65, 95%CI:0.18-2.42, p=0.524) and non-RCT (RR:0.77, 95%CI: 0.39-1.53, p=0.459) analysis (16). While the follow-up length of our included studies was 90 days to 6 months, long-term studies that provided sufficient evidence on warfarin-related and all-cause death in different anticoagulation management models were expected.…”

“…Nevertheless, some studies showed no significant difference between pharmacist management and other management models in INR control results (14,15). Saokaew et al performed a meta-analysis that including RCTs, cohort studies and quasi-experimental studies in 2010 which found pharmacist-participated warfarin therapy management (PWTM) had statistically significant effects on the prevention of total bleeding of RCTs and non-RCTs (16). Another meta-analysis that including eight randomized controlled trials (RCTs) by Zhou et al showed a significant difference between pharmacist-managed care and other management models for satisfaction and the percentage of time within the standard therapeutic range, but no significant improvement on the bleeding and thrombosis events (17).…”