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

Abstract

To cite this article: Manji I, Pastakia SD, Do AN, Ouma MN, Schellhase E, Karwa R, Miller ML, Saina C, Akwanalo C. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost 2011; 9: 2215-20.Summary. 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. WilcoxonÕs 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 followup 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.

A mechanical heart valve is the best choice

“…Though the mean TTR for all-comers is numerically lower than the TTR achieved in the Australian clinic, it is again comparable to a TTR achieved in well-conducted clinical trials of warfarin 21. Importantly, the subset of patients with a mechanical heart valve achieved similar outcomes to the Australian group,20 thereby suggesting that a rural setting and living in a developed nation do not necessarily disadvantage or advantage patients in the management of outpatient anticoagulation. In summary, the likelihood for anticoagulation in this patient, the need for a cost-effective solution, and the management of monitoring of a VKA have all been described as achievable within this patient's context, and therefore, we would contend that this strengthens our position in arguing for a mechanical heart valve.…”

“…Again, it may be argued that Australia is a developed nation and a similar outcome would be harder to achieve in a low/middle-income nation due to a lack of resources. However, Manji et al report similar success in an anticoagulation clinic in rural Kenya 20. In this study, they developed a pharmacist-led anticoagulation clinic using point-of-care devices based from a clinic in Eldoret, Kenya.…”

“…In this study, they developed a pharmacist-led anticoagulation clinic using point-of-care devices based from a clinic in Eldoret, Kenya. They noted that with education and regular follow-up, the mean TTR was 64.6% in all-comers, but in the group with mechanical heart valves, the mean TTR was 77% 20. Though the mean TTR for all-comers is numerically lower than the TTR achieved in the Australian clinic, it is again comparable to a TTR achieved in well-conducted clinical trials of warfarin 21.…”

“…One could argue that this monitoring is problematic in such a patient. However, monitoring practices have been established within such jurisdictions before 19 20. Hodge et al describe the development of a comprehensive INR management programme based in community hospitals and general practitioner clinics in rural Australia 19.…”

Describing the Profile of Patients on Concurrent Rifampin and Warfarin Therapy in Western Kenya: A Case Series

“…Because of the higher prevalence of TB and emerging availability of anticoagulation services in this setting, there exists a growing population of patients who are facing this drug interaction [18, 19]. Even though anticoagulation clinics have been shown to improve patient outcomes when compared to individual physician care, the limited data concerning this drug–drug interaction in this population presents an enormous challenge to clinicians providing care to patients on concomitant rifampicin and warfarin therapy [2].…”