Pharmacy Technician Management of Stable, In-Range INRs Within a Clinical Pharmacy Anticoagulation Service

Abstract

BACKGROUND: There is increasing demand on pharmacist time within clinical pharmacy services, and pharmacy technicians are a crucial resource for expanding pharmacy practice. OBJECTIVE: To assess the safety and effectiveness of pharmacy technician management of stable, in-range international normalized ratio (INR) results compared with usual care. METHODS: This retrospective, longitudinal, noninferiority cohort study was conducted at an integrated health care delivery system with a centralized anticoagulation service. Adult patients receiving chronic warfarin therapy with therapeutic INR results over a 3-month period (i.e., 100% time in therapeutic range [TTR] during the 3 months before the index date) were eligible for referral to technician warfarin management between March 1, 2015, and December 31, 2015. Patients with similar INR control during the same period but not referred to technician management were included as comparators in the usual care group. A one-sided noninferiority margin for the technician management group was set to -2.5% for mean TTR. Propensity scoring was used in regression modeling via inverse probability of treatment weights to compare between-group differences to account for covariates that may have influenced assignment to the technician group. Finally, bleeding, thromboembolic, and mortality outcomes were compared.RESULTS: 1,840 and 1,116 patients were included in the technician and usual care groups, respectively. The mean age of included patients was 73.1 years, and the majority (77.9%) had received warfarin for > 3 years. TTR during follow-up was 83.3% and 77.7% in the technician and usual care groups, respectively (mean difference = 5.7%; 95% CI = 4.1%-7.2%). The risk of thromboembolism was similar between the technician and usual care groups (HR = 0.84; 95% CI = 0.17-4.22; P = 0.832); however, bleeding (HR = 0.60; 95% CI = 0.39-0.94; P = 0.026) and all-cause mortality (HR = 0.44; 95% CI = 0.25-0.77; P = 0.004) were lower in the technician group during follow-up.CONCLUSIONS: Technician management of stable patients receiving chronic warfarin therapy within an integrated health care delivery system's centralized anticoagulation service was associated with noninferior TTR results compared with usual care pharmacist management.

Using pharmacy technicians and electronic health record capabilities to improve outcomes for patients with cardiovascular disease

“…One study demonstrated similar time in therapeutic range using pharmacy technicians to assess international normalized ratios (INRs) among patients receiving chronic warfarin compared with pharmacists (83.3% and 77.7% in the technician and pharmacist groups, respectively, P < 0.05). 22 Furthermore, although there was no difference in thromboembolism between groups, there was lower bleeds and all-cause mortality in the technician group. 22 Another study conducted at the Veteran's Affairs demonstrated that more than 50% of tasks performed by pharmacists within their anticoagulation services, including telephone follow-up to patients with in-range INRs, could be handled by pharmacy technicians, resulting in greater than $55,000 annual cost-savings.…”

“…The CPCRS has demonstrated improved surrogate, clinical, and economic outcomes among the patients enrolled. [20][21][22] Patients in the EPIC Healthy Planet registry are categorized in "active" or "surveillance" mode based on whether they have attained all of their cardiovascular risk reduction goals (lipids and BP, appropriate statin intensity, adherent to medications). Patients in "surveillance" mode get yearly lipid monitoring.…”

“…The few clinical areas that have evaluated the use of EHR functionalities and pharmacy technicians have primarily been focused in anticoagulation, pain management, and, to a small degree, postfracture care for patients with osteoporosis. [22][23][24][25] Although these studies provide evidence of successfully integrating pharmacy technicians into some aspects of ambulatory pharmacy processes of care, there are many other areas of pharmacy practice that have yet to be evaluated. Data on the impact of incorporating pharmacy technicians into ambulatory pharmacy practice on clinical outcomes and ability to shift work from pharmacists are sparse.…”

Wage Premiums as a Means to Evaluate the Labor Market for Pharmacy Technicians in the United States: 1997–2018

“…Since 2006 wage premiums for pharmacy technicians in the US have fluctuated in a manner and to a degree similar to those experienced by the median of "all occupations" in the US economy. Yet, what has been asked of pharmacy technicians in terms of expanded job roles [4][5][6][7][8][9][10][11][12] and regulatory requirements [21][22][23] has increased over this time. While one would expect to see positive wage premiums as a result of these increases in job roles and requirements, this was not observed in our analysis, and is consistent with the findings of other researchers [21,22].…”

“…Pharmacy technicians support pharmacists in dispensing medications, performing clinical functions needed to improve the outcomes of mediation use [4][5][6], and to perform a number of administrative functions which assist in the operations of a pharmacy [7]. Pharmacy technicians have been asked to increasingly take on roles that had previously been exclusively performed by pharmacists, including reviewing medications and checking the work of other technicians prior to dispensing [8,9], taking medication histories [10], managing warfarin therapy within a clinical pharmacy anticoagulation service [11] and immunization delivery [12]. Pharmacists depend upon a stable labor market of pharmacy technicians to support them in optimizing patient health outcomes.…”