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International Journal of Clinical Pharmacy

, Volume 40, Issue 5, pp 1078–1085 | Cite as

Pharmacist’s interventions improve time in therapeutic range of elderly rural patients on warfarin therapy: a randomized trial

  • Slaven FalamićEmail author
  • Marko Lucijanić
  • Maja Ortner Hadžiabdić
  • Srećko Marušić
  • Vesna Bačić Vrca
Research Article
  • 107 Downloads

Abstract

Background Community pharmacists can play an important role in optimizing warfarin treatment, which is very important in vulnerable patient groups such as the elderly patients in rural areas. Objective To evaluate the impact of a community pharmacist’s interventions on the quality of anticoagulation in elderly rural patients receiving warfarin. Setting A community pharmacy in Donji Miholjac in Croatia’s province of Slavonia. Method We conducted a prospective randomized trial. Eligible patients were recruited at the pharmacy and randomized into two groups. All participants were followed up monthly for a period of 6 months. Repeated education and a follow up plan were provided to the participants in the intervention group, and their general practitioners were contacted to correct the warfarin dose or to avoid drug interactions. Main outcome measure Time in therapeutic range (TTR) calculated by the Rosendaal method. Results A total of 140 patients were randomized and 131 patients finished the study, 65 patients in the intervention group. Median age was 73 years. At the end of the follow-up period, the median TTR was significantly higher in the intervention group (93 vs. 31.2% for intervention and control, respectively; P < 0.001). The proportion of patients with TTR ≥ 65% was also significantly higher in the intervention group (86.2 vs. 7.6% for intervention and control, respectively; P < 0.001). Factors independently associated with TTR ≥ 65% were intervention (P < 0.001), less frequent dose change (P = 0.005), better adherence (P < 0.001) and less variable vitamin K intake (P = 0.010).

Keywords

Croatia Elderly Pharmacist intervention Anticoagulation Rural population Warfarin 

Notes

Acknowledgements

Study is a part of Ph.D. thesis of the first author. The authors would like to acknowledge all the general practitioners for their assistance: Dr. Nada Dumančić, Dr. Spomenka Drašinac Kurtagić, Dr. Vanda Balković, Dr. Dahna Jantoš, Dr. Brankica Brlić Tarbuk, Dr. Vjeran Bogović, Dr. Wadi Zoghbi, Dr. Tatjana Bakaran and Dr. Ljubica Toth.

Funding

This study was self-funded.

Conflicts of interest

None declared.

References

  1. 1.
    Capodanno D, Angiolillo DJ. Antithrombotic therapy in the elderly. J Am Coll Cardiol. 2010;56(21):1683–92.CrossRefGoogle Scholar
  2. 2.
    Klotz U. Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev. 2009;41:67–76.CrossRefGoogle Scholar
  3. 3.
    Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004;329(7456):15–9.CrossRefGoogle Scholar
  4. 4.
    Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Pub Health. 2015;129:611–20.CrossRefGoogle Scholar
  5. 5.
    Rossiter J, Soor G, Telner D, Aliarzadeh B, Lake J. A Pharmacist-led point-of-care INR clinic: optimizing care in a family health team setting. Int J Family Med. 2013;2013:691454.  https://doi.org/10.1155/2013/691454.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Harrison J, Shaw JP, Harrison JE. Anticoagulation management by community pharmacists in New Zealand: an evaluation of a collaborative model in primary care. Int J Pharm Pract. 2015;23:173–81.CrossRefGoogle Scholar
  7. 7.
    Manji I, Pastakia SD, Do AN, Ouma MN, Schellhase E, Karwa R, et al. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost. 2011;9:2215–20.CrossRefGoogle Scholar
  8. 8.
    Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost. 1993;69(3):236–9.CrossRefGoogle Scholar
  9. 9.
    Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest. 2008;133:160S–98S.CrossRefGoogle Scholar
  10. 10.
    Franco V, Polanczyk CA, Clausell N, Rohde LE. Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols. Am J Med. 2004;116(10):651–6.CrossRefGoogle Scholar
  11. 11.
    Lip GYH, Halperin JL. Improving stroke risk stratification in atrial fibrillation. Am J Med. 2010;123:484–8.CrossRefGoogle Scholar
  12. 12.
    Pisters R, Lane DA, Nieuwlaat R, De Vos CB, Crijns HJGM, Lip GYH. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the euro heart survey. Chest. 2010;138:1093–100.CrossRefGoogle Scholar
  13. 13.
    Maes KA, Studer H, Berger J, Hersberger KE, Lampert ML. Documentation of pharmaceutical care: validation of an intervention oriented classification system. J Eval Clin Pract. 2017;23(6):1425–32.CrossRefGoogle Scholar
  14. 14.
    Young S, Bishop L, Twells L, Dillon C, Hawboldt J, O’Shea P, et al. Comparison of pharmacist managed anticoagulation with usual medical care in a family medicine clinic. BMC Fam Pract. 2011;12:88.CrossRefGoogle Scholar
  15. 15.
    Entezari-Maleki T, Dousti S, Hamishehkar H, Gholami K. A systematic review on comparing 2 common models for management of warfarin therapy; pharmacist-led service versus usual medical care. J Clin Pharmacol. 2016;56:24–38.CrossRefGoogle Scholar
  16. 16.
    Víquez-jaikel A, Hall-Ramírez V, Ramos-Esquivel A. Improvement of time in therapeutic range with warfarin by pharmaceutical intervention. Int J Clin Pharm. 2017;39(1):41–4.CrossRefGoogle Scholar
  17. 17.
    Saokaew S, Sapoo U, Nathisuwan S, Chaiyakunapruk N, Permsuwan U. Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand. Int J Clin Pharm. 2012;34(1):105–12.CrossRefGoogle Scholar
  18. 18.
    Gallagher J, Mc Carthy S, Woods N, Ryan F, O’Shea S, Byrne S. Economic evaluation of a randomized controlled trial of pharmacist-supervised patient self-testing of warfarin therapy. J Clin Pharm Ther. 2015;40:14–9.CrossRefGoogle Scholar
  19. 19.
    Clarkesmith DE, Pattison HM, Lip GY, Lane DA. Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial. PLoS ONE. 2013;8(9):e74037.CrossRefGoogle Scholar
  20. 20.
    Šupe S, Božina N, Matijević V, et al. Prevalence of genetic polymorphisms of CYP2C9 and VKORC1—implications for warfarin management and outcome in Croatian patients with acute stroke. J Neurol Sci. 2014;343(1–2):30–5.CrossRefGoogle Scholar
  21. 21.
    Singer DE, Hellkamp AS, Piccini JP, et al. Impact of global geographic region on time in therapeutic range on warfarin anticoagulant therapy: data from the ROCKET AF clinical trial. J Am Heart Assoc. 2013;2(1):e000067.  https://doi.org/10.1161/JAHA.112.000067.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mearns ES, White CM, Kohn CG, Hawthorne J, Song J-S, Meng J, et al. Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression. Thromb J. 2014;12:14.CrossRefGoogle Scholar
  23. 23.
    Fang MC, Go AS, Hylek EM, Chang Y, Henault LE, Jensvold NG, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004;141(10):745–52.CrossRefGoogle Scholar
  24. 24.
    Wieloch M, Själander A, Frykman V, Rosenqvist M, Eriksson N, Svensson PJ. Anticoagulation control in Sweden reports of time in therapeutic range, major bleeding, and thrombo-embolic complications from the national quality registry AuriculA. Eur Heart J. 2011;32:2282–9.  https://doi.org/10.1093/eurheartj/ehr134 CrossRefPubMedGoogle Scholar
  25. 25.
    Penning-van Beest FJ, Koerselman J, Herings RMC. Quantity and quality of potential drug interactions with coumarin anticoagulants in the Netherlands. Pharm World Sci. 2007;29:671–5.CrossRefGoogle Scholar
  26. 26.
    Mazor KM, Baril J, Dugan E, Spencer F, Burgwinkle P, Gurwitz JH. Patient education about anticoagulant medication: is narrative evidence or statistical evidence more effective? Patient Educ Couns. 2007;69:145–57.CrossRefGoogle Scholar
  27. 27.
    Nochowitz B, Shapiro NL, Nutescu EA, Cavallari LH. Effect of a warfarin adherence aid on anticoagulation control in an inner-city anticoagulation clinic population. Ann Pharmacother. 2009;43(7):1165–72.CrossRefGoogle Scholar
  28. 28.
    Cryder B, Felczak M, Janociak J, Dela pena L, Allen S, Gutierrez P. Prevalent aetiologies of non-therapeutic warfarin anticoagulation in a network of pharmacist-managed anticoagulation clinics. J Clin Pharm Ther. 2011;36(1):64–70.CrossRefGoogle Scholar
  29. 29.
    Tan KM, Tallon E, Noone I, Hughes G, O’Shea D. Crowe M Difficulties encountered by the very elderly with atrial fibrillation on warfarin attending an outpatient anticoagulant monitoring service. Eur Geriatr Med. 2012;3:78–81.CrossRefGoogle Scholar
  30. 30.
    Jackson SL, Peterson GM, Bereznicki LR, Misan GM, Jupe DM, Vial JH. Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy. J Clin Pharm Ther. 2005;30(4):345–53.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Community Pharmacy Branka MarušićDonji MiholjacCroatia
  2. 2.Hematology DepartmentUniversity Hospital DubravaZagrebCroatia
  3. 3.Centre for Applied PharmacyUniversity of Zagreb, Faculty of Pharmacy and BiochemistryZagrebCroatia
  4. 4.Department of Clinical pharmacologyUniversity Hospital DubravaZagrebCroatia
  5. 5.Department of Clinical pharmacyUniversity Hospital DubravaZagrebCroatia

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