Management of Chinese patients on warfarin therapy in two models of anticoagulation service – a prospective randomized trial

Abstract

AimTo compare the treatment outcomes of a clinical pharmacist-managed anticoagulation service with physician-managed service in Chinese patients. MethodsA prospective, randomized clinical trial was conducted at the anticoagulation clinic of a teaching hospital in Hong Kong. Patients aged ≥ 18 years who would required warfarin therapy for at least 3 months were recruited. Patients were randomized to the pharmacist-managed or physician-managed group. Primary clinical outcome was assessed by the percentage of patient time spent within the target international normalized ratio (INR) range. The incidence of major thromboembolic events (TEs) and major bleeding was assessed as secondary clinical outcomes. The cost per patient per month (cPPPM) was calculated and patient satisfaction was assessed by patient satisfaction questionnaire (PSQ)-18. ResultsOne hundred and forty-one patients were recruited at the anticoagulation clinic and 137 patients completed the study. Patients in the pharmacist-managed group ( n = 68) were in the target INR 64% of patient time vs. 59% in the physicianmanaged group ( n = 69) ( P < 0.001). There was no significant difference in incidence of major TEs or bleeding. The cPPPM in the pharmacist-managed group (US$76 ± 95) (£43 ± 53) was lower than in the physician-managed group (US$98 ± 158) (£55 ± 89) ( P < 0.001). The PSQ-18 score of the pharmacist-managed group (3.8 ± 0.2) was higher than that of the physician-managed group (3.6 ± 0.3) ( P < 0.001). ConclusionThe pharmacist-managed anticoagulation service was more effective and less costly than the physician-managed service in achieving target anticoagulation control for Chinese patients on warfarin therapy.

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

“…The patient satisfaction questionnaire (PSQ-18) (RAND Corporation, Santa, Monica, CA, USA) was applied by Chan et al, which was a seven scales assessment including general satisfaction and similar results came from two groups. The overall score of pharmacist-managed group were significantly higher than that of physician-managed group (3.8±0.2 vs 3.6±0.3, p<0.001) (24).…”

“…The publication bias was not found from Egger's test result (p=0.155) and Begg's test result (p=0.221) and the result was robust showed in the sensitivity analysis. (14,15,22,24), reported patient satisfaction with different oral anticoagulation management models. The patient treatment satisfaction measured by 3 different surveys and questionnaires.…”

“…One RCT (24), and 2 observational cohort study (11,33), reported cost of anticoagulation management in different currency units and time units. Chan et al indicated a significant reduction of the cost per patient per month in pharmacist management group ($76±95 vs $98±158, p<0.01, 2006) (24).…”

“…For the major haemorrhage events, pooled results from 7 RCTs (14,15,(23)(24)(25)(26)(27), and 7 cohort studies (11,12,28,(30)(31)(32)34) Figure 4C). Major haemorrhage events was defined as "major bleeding" of the International Society of Thrombosis and Hemostasis (ISTH) which including fatal bleeding in non-surgical patients, symptomatic bleeding, bleeding causing a fall in hemoglobin level of 20g/L, or need for transfusion (36).…”

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

“…[11][12][13][14][15][16][17] For anticoagulation centers with average TTR of 60 % or below, the possible options are either the use of more expensive NOACs, or providing additional resources to improve TTR. Various therapeutic strategies to improve TTR have been examined and the findings suggest that employment of a clinical factor-guided dosing algorithm, 18 frequent INR monitoring, [19][20][21] and management of anticoagulation care by specialists in the use of anticoagulants 22,23 are effective interventions. Each alternative has different economic and clinical implications for patients, clinicians and decision-makers to consider.…”