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Optimising Warfarin management: an exploration of pharmacist-delivered models of care


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van Tienen, EC 2012 , 'Optimising Warfarin management: an exploration of pharmacist-delivered models of care', PhD thesis, University of Tasmania.

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Warfarin has been the mainstay of preventing and treating thromboembolism for
over 50 years and is currently taken by over 200,000 Australians. Optimal
management of warfarin relies on regular monitoring of the International
Normalised Ratio (INR), appropriate dose adjustment, effective communication and
comprehensive patient education. Therapy may be managed by a range of
healthcare providers in a variety of settings, and by patients themselves, although
management in Australia has tended to focus on traditional office and pathology based
models. Internationally, however, alternative models of care are playing an
increasingly significant role with positive results and pharmacists have been shown
to be effective in improving the quality use of warfarin through a variety of these
service delivery models.
The main objective of this thesis was to examine the effect of using pharmacist delivered
models of care on warfarin management within Australia through a
number of complementary projects.
Guidelines recommend aiming for a target INR control of upwards of 70% time in
range. Internationally, community-based studies consistently demonstrate
suboptimal levels of INR control, although little data is available on the level of
control achieved through usual models of care in Australia. A retrospective cross sectional
study of INR results from 442 Australian veterans was undertaken to
determine the INR control of a usual care population. The mean time in INR range
was 61.8% in this population. This suggests a potential role for strategies aiming to
improve INR control among Australian patients in line with best practice guidelines.
Review of the literature suggested pharmacists could play a role in improving
warfarin management through optimising the delivery of education, improving
access to INR testing and facilitating patient self-monitoring. A series of sub-projects were designed to develop and pilot tools to support pharmacists in addressing these
A website was designed to provide patients and health professionals with
educational resources regarding anticoagulation. The site aimed to be a
comprehensive and reliable online resource and was promoted directly to
pharmacists. It received high levels of utilisation, with almost 250,000 views in 12
months, and positive feedback from health professionals and patients, and proved to
be an important educational resource that was an easy and accessible tool for
pharmacists to use to complement face to face counselling services and further
improve patients’ knowledge about warfarin therapy.
Tools and resources were developed to improve access to INR testing by facilitating
the introduction of anticoagulation services, including pharmacist-delivered INR
clinics, in Australia. A pilot was conducted in three rural community pharmacies,
with a subsequent project involving 36 pharmacies. While the resources received
positive feedback from participating pharmacists, the rate of successful service
implementation was low. Despite the perceived benefits to the communities, the
current model of healthcare remuneration in Australia impacted on the long term
financial viability of such services.
Development, implementation and evaluation of a pharmacy-centred pathway to
enable patient self-monitoring (PSM) was also undertaken. Forty-eight patients
successfully underwent training and participated in PSM for a median of 16.9
months. INR control data during PSM was compared to that from the six months
prior to entering the study for 46 of the 48 patients. There was a significant
improvement in INR control, with the mean time in range increasing from 64.0% to
72.9% (p<0.05). Clinical data analysis was complemented by a qualitative
exploration of 38 patients’ experiences of self-monitoring and the impact of PSM on various aspects of their lives. It was found that patients discussed PSM positively,
describing it passionately and as something of value, which reduced their anxiety
and freed them to carry on with their lives.
The results of these projects suggest that expansion of the professional services
offered by pharmacists has the potential to improve the control of warfarin therapy
in Australia. Changes in remuneration for healthcare services are likely to increase
the viability of pharmacist-delivered INR services and the uptake of PSM. Despite
the arrival of newer oral anticoagulant agents, the use of warfarin is likely to
continue for many years. Optimising warfarin management is arguably the safest
and most clinically and cost-effective option for preventing and treating
thromboembolism at this point in time. Pharmacists can play an important role in
improving warfarin management by embracing opportunities to deliver professional
services aimed at optimising outcomes for Australians taking warfarin.

Item Type: Thesis - PhD
Authors/Creators:van Tienen, EC
Keywords: Pharmacy, anticoagulation, warfarin, INR control, patient self-monitoring, pharmacist services
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