RESUMEN
OBJECTIVE: To determine the process for establishing community pharmacy-based anticoagulation education and monitoring programs using fingerstick capillary whole blood testing. DESIGN: Pilot community-based intervention study using convenience sample of patients. SETTING: Three community pharmacies with pre-established health education centers and laboratories certified for moderate complexity. PARTICIPANTS: 26 patients were referred to the clinics by 2 primary care physicians for each pharmacy, most with a diagnosis of atrial fibrillation. INTERVENTION: Patient assessment, including adherence to prescribed regimens; changes in medication use, including prescription and nonprescription medications, vitamins, health foods, and nutrition supplements; changes in diet and ethanol consumption; assessment of adverse experiences; and needed changes in warfarin dosage. MAIN OUTCOME MEASURES: Percentage of international normalized ratio (INR) values within therapeutic range, major bleeding events, and thrombotic events. RESULTS: A total of 21 patient charts were available for analysis. More than 80% of patients had INR values within their targeted range (+/- 0.2) 60% or more of the time, comparable with values reported for anticoagulation clinics. Of the 235 INR values obtained during the study, 75% were within the individualized targeted therapeutic range (e.g., 2 to 3 +/- 0.2). One patient experienced a major bleeding event related to an underlying cancer. None of the patients experienced a thrombotic event. CONCLUSION: Community pharmacies can effectively implement an anticoagulation education and monitoring program.
Asunto(s)
Anticoagulantes/uso terapéutico , Monitoreo Fisiológico , Educación del Paciente como Asunto , Farmacias/normas , Adulto , Anciano , Anticoagulantes/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Tiempo de Protrombina , Estados UnidosRESUMEN
OBJECTIVE: To provide primary and referring healthcare practitioners with guidelines for the provision of safe and effective anticoagulation management in any venue to standardize and improve quality of care and to permit negotiation for reimbursement from third-party payers. DATA EXTRACTION AND SYNTHESIS: Data on the current practice of anticoagulation providers and outcomes related to anticoagulation clinic care were obtained through the literature, interviews with anticoagulation providers, and a focus group meeting of anticoagulation clinic stakeholders. This information collation process revealed that an anticoagulation service consists of three separate areas for which guidelines should be developed. Based on the consensus opinions of the committee members, the literature review, and the current practice of anticoagulation services providers, a draft guideline was developed and reviewed by an independent multidisciplinary panel of anticoagulation services providers whose comments were incorporated into the final guideline. CONCLUSIONS: Systematic outpatient anticoagulation services are systems of care designed to coordinate and optimize the delivery of anticoagulation therapy by (1) evaluating patient-specific risks and benefits to determine the appropriateness of therapy; (2) facilitating the management of anticoagulation dosages and prescription pick up or delivery; (3) providing ongoing education of the patient and other caregivers about warfarin and the importance of self-care behavior leading to optimal outcomes; (4) providing continuous systematic monitoring of patients, international normalized ratio results, diet, concomitant drug therapy, and disease states; and (5) communicating with other healthcare practitioners involved in the care of the patient. To create a reproducible framework for the provision of these services, guidelines for structure, process, and outcomes of coordinated outpatient anticoagulation management services were developed. Guidelines for organization and management include (1) qualifications for personnel, (2) supervision, (3) care management and coordination, (4) communication and documentation, and (5) laboratory monitoring. Guidelines for the process of patient care include (6) patient selection and assessment, (7) initiation of therapy, (8) maintenance and management of therapy, (9) patient education, and (10) management and triage of therapy-related and unrelated problems. Guidelines for the evaluation of patient outcomes include (11) organizational components and (12) patient outcomes. The impact of these 12 guidelines on patient care and reimbursement procurement will depend on their implementation and the perceived value of their use.