The Role of Community Pharmacy in Post Hospital Management of Patients Initiated on Warfarin
|Institution:||University of Tasmania|
|Chief Investigator:||Professor Greg Peterson|
Patients discharged from hospital on warfarin are at high risk of bleeding and thrombotic (clotting) adverse events in the period after discharge, and therefore require more frequent monitoring of their International Normalised Ratio (INR), the blood test used to monitor the anticoagulant (anti-clotting) effect of warfarin.
A post-discharge warfarin management service was trialled in a prospective controlled cohort study in eight sites in Tasmania, SA and NSW. Patients received two or three home visits by a trained accredited pharmacist in their first 8 to 10 days after discharge. The service provided point-of-care INR monitoring using a finger prick blood test, warfarin education and a home medicines review, in collaboration with a patient’s GP and community pharmacist. Sixteen patients were subsequently trained to self-monitor their INRs (known as ‘patient self-monitoring’, or PSM), with the option of communicating their results to their GP via www.anticoagulation.com.au.
The outcomes of 129 patients receiving the post-discharge service were compared to those of 139 receiving usual care, which involved traditional GP or pathology-based INR testing. A non-statistically significant reduction in the rate of major bleeding events in the 90 days after hospital discharge was demonstrated. There were also no statistically significant decreases in the rates of major bleeding or thrombotic events (although a positive trend was observed), unplanned hospital readmissions or death. The service was associated with decreased rates of total bleeding events, and combined bleeding and thrombotic events at both Day 8 and Day 90 after discharge, and improved persistence with warfarin therapy. A short-term improvement in warfarin knowledge was also achieved. Stakeholder feedback was generally very positive, especially regarding the convenience of the home visits and the improved opportunity for warfarin education.
An economic analysis of the service revealed that it was associated with significant savings in warfarin-related healthcare costs in the post-discharge period. PSM was associated with improved INR control, and stakeholder satisfaction with both PSM and the internet platform was very high.
While the study’s limitations prevent the outcomes of the service being generalised to the entire population of patients taking warfarin after discharge from hospital, the results provide solid evidence to suggest that the optimal implementation of pharmacy-based anticoagulation management services has the potential to improve the health outcomes of eligible patients and reduce healthcare costs, especially those associated with warfarin-related hospital readmissions.