RESUMEN
OBJECTIVES: Good warfarin knowledge is important for optimal patient outcomes, but barriers exist to effective education and warfarin knowledge is often poor. This study aimed to explore the educational outcomes of home-based warfarin education provided by trained pharmacists. METHODS: In a prospective, non-randomised, controlled cohort trial, patients received either usual community-based post-discharge care or a post-discharge warfarin management service, including warfarin education by trained pharmacists during two or three home visits. Patients' warfarin knowledge was assessed at 8 and 90 days post-discharge using the Oral Anticoagulation Knowledge test. KEY FINDINGS: One hundred and thirty-nine patients were recruited into the usual care group between November 2008 and August 2009, and 129 into the intervention group between May and December 2009. Pharmacist-delivered warfarin education was associated with a significant difference between the intervention patients' baseline and day 8 mean warfarin knowledge scores of 64.5% (95% confidence interval (CI) 61.0-68.5%) and 78.0% (95% CI 74.5-81.5%; P < 0.001), respectively. The intervention patients also scored significantly higher than the usual care patients at day 8 (65.0%, 95% CI 61.5-68.0%; P < 0.001), but not at day 90. CONCLUSIONS: Use of an existing healthcare framework overcame several systemic barriers by facilitating warfarin education in patients' homes. While the intervention was associated with better short-term warfarin knowledge, follow-up may be required to optimise its benefits. Widespread implementation of home-based warfarin education by pharmacists has the potential to contribute significantly to improved outcomes from warfarin therapy.
Asunto(s)
Anticoagulantes/uso terapéutico , Educación del Paciente como Asunto/métodos , Farmacéuticos/organización & administración , Warfarina/uso terapéutico , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Conocimientos, Actitudes y Práctica en Salud , Servicios de Atención de Salud a Domicilio/organización & administración , Humanos , Masculino , Persona de Mediana Edad , Servicios Farmacéuticos/organización & administración , Rol Profesional , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period. OBJECTIVE: To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program. METHODS: In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy at 8 and 90 days postdischarge. RESULTS: The PDS (n=129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p=0.03) and day 8 (0.9% vs 7.2%; p=0.01) compared with UC (n=139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p=0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p=0.004). No significant differences in readmission and death rates or INR control were demonstrated. CONCLUSIONS: This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence in patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care.
Asunto(s)
Anticoagulantes/uso terapéutico , Servicios de Atención de Salud a Domicilio/organización & administración , Warfarina/uso terapéutico , Anticoagulantes/administración & dosificación , Australia , Estudios de Cohortes , Femenino , Humanos , Relación Normalizada Internacional , Masculino , Alta del Paciente , Readmisión del Paciente , Estudios Prospectivos , Resultado del Tratamiento , Warfarina/administración & dosificaciónRESUMEN
OBJECTIVE: To describe the development, implementation and outcomes of an anticoagulation education program for pharmacists participating in a community-based post-discharge warfarin management service. SETTING: Australian community pharmacy practice. METHOD: Three education modules were developed in collaboration with medical experts and delivered electronically and via hands-on training sessions to pharmacists in three Australian states. Educational outcomes were assessed via a short answer assignment and evaluation of their warfarin dosing recommendations for five hypothetical scenarios. Consumer and pharmacist perceptions of the adequacy of the training were surveyed using a structured postal questionnaire. MAIN OUTCOME MEASURE: Pharmacists' score in the short answer assignment and evaluation of their responses to the hypothetical warfarin dosing scenarios. RESULTS: Sixty-two pharmacists successfully completed the training program with a mean score for the short answer assignment of 14.3 out of 15 (95.3%; 95% CI 13.8-14.7). The pharmacists' warfarin management recommendations were very similar to those of two experienced medical specialists. Pharmacists and consumers expressed confidence in the adequacy of the training program. CONCLUSION: This education program successfully up-skilled a cohort of pharmacists for involvement in a post-discharge warfarin management service. These findings support formalization and further development of the program to facilitate widespread implementation of home-based post-discharge warfarin care.