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Undergraduate
Category:HealthScience
DegreeLevel:Pharm.D.
AbstractID#1127
Evaluation of Warfarin Anticoagulation
Management at a Community Health
Center
Elaina D. Rosario and Michelle Jacobs, Pharm.D., CDE
Abstract
Background: The safety and efficacy of warfarin depend on maintaining the
international normalized ratio (INR) blood level in an established range.
Objective: The purpose was to evaluate the warfarin panel of patients’ percent in/out
range when using a primary care provider (PCP)-led approach versus a pharmacistled (75% of the time) and nurse practitioner-led (25% of the time) approach as a
quality assurance measure for a community health center in Dorchester, MA.
Methods: A retrospective chart review was conducted collecting INR data for patients
receiving warfarin management by their PCP from May 1, 2013 to May 1, 2014.
These were compared to INR results from August 1, 2014 to August 1, 2015, during
which time the same patients received warfarin management from a pharmacist and
nurse practitioner (NP). The primary end points were percentage of INRs within a
specified goal range (either 2.0-3.0 or 2.5-3.5) and an expanded goal range of ±0.2
the specified INR goal range for the PCP-led group versus the pharmacist/NP-led
group.
Results: The percentage of INR results within the specified goal range was greater
among patients in the PCP-led group (n=70; 56%) than the pharmacist/NP-led group
(n=78; 53%). The percentage of INR results within an expanded; more clinically
relevant goal range was the same between the physician-led group (n=70; 72%) and
the pharmacist/NP-led group (n=78; 72%).
Conclusion: The warfarin INR management between the PCP-led and pharmacist/
NP-led groups were similar and consistent with overall good therapeutic management
in order to reduce embolic events or bleeding risk.
Background
•  DotHouse Health is a community health center located in Dorchester, MA that
provides comprehensive primary care, dental, eye, and behavioral health services.
Clinical pharmacy is an integral part of DotHouse Health providing clinical expertise
in disease and drug management. Historically, warfarin INR management had been
led by the patient’s primary care provider (PCP). From June to August 2014 there
was a transition of INR management from the PCP to the clinical pharmacist (75%
of the time) and a nurse practitioner (25% of the time).
•  Warfarin is the most common oral anticoagulant used in the United States to
prevent and treat thromboembolic events.
•  Because warfarin has a narrow therapeutic range it is important to routinely monitor
warfarin drug levels in order to keep them within an established range to prevent
embolic events when the drug level is too low or adverse events such as bleeding
when the level is too high. In addition there are many factors that could potentially
interact with warfarin such as food, other drugs, and health status.
•  There have been many studies that evaluated the differences between pharmacistled anticoagulation management and physician-led anticoagulation management. In
one meta-analysis of 67 studies involving 50,208 patients followed for a total of
57,155 patient-years showed that there was an absolute difference of 8.3%
between pharmacist-led anticoagulation management and physician-led
anticoagulation management, favoring pharmacist-led anticoagulation
management. According to another study, pharmacist-led anticoagulant
management also showed an economic benefit in a pharmacist-run anticoagulant
clinic.
Objectives
•  Assist with weekly clinical management of patients’ INR results.
•  Conduct a quality assurance evaluation of INR readings for active warfarin
patients from May 1, 2013-May 1, 2014, when warfarin was managed by the PCP,
and from August 1, 2014-August 1, 2015, when warfarin was managed by the
clinical pharmacist and NP.
Methods
•  Collected INR data for patients receiving warfarin management by their PCP from
May 1, 2013 to May 1, 2014.
•  Collected INR data for the same patients receiving warfarin management by the
clinical pharmacist and NP from August 1, 2014 to August 1, 2015.
•  Recorded data in a Microsoft Excel spreadsheet to facilitate data analysis.
Results
May2013–May2014
PCP-ledWarfarinManagement
N=70
24%
In
Above
56%
Conclusions
•  This data reflects strict INR range defined as
2-3 or 2.5-3.5.
•  This data shows the percent in goal range, the
percent above goal range, and the percent
below goal range for the PCP-led warfarin
management from May 1, 2013 to May 1,
2014.
•  The percent in goal range is greatest during
this time period (56%).
Below
20%
August2014–August2015
ClinicalPharmacist/NP-ledWarfarinManagement
•  This data reflects strict INR range defined as
2-3 or 2.5-3.5.
•  This data shows the percent in goal range, the
percent above goal range, and the percent
below goal range for the clinical pharmacist/
NP-led warfarin management from August 1,
2014 to August 1, 2015.
•  The percent in goal range is greatest during
this time period (53%).
May2013–May2014
PCP-ledWarfarinManagement
N=70
17%
In
Above
11%
72%
Below
N=78
31%
In
53%
Above
Below
17%
•  This data reflects 0.2 below and above the INR
goal range (e.g., 1.8-3.2 for an INR goal of 2-3).
•  This data shows the percent in goal range, the
percent above goal range, and the percent
below goal range for the PCP-led warfarin
management from May 1, 2013 to May 1, 2014.
•  Many clinical studies use an expanded INR goal
range (1.8-3.2) when evaluating percent of INRs
in or out of therapeutic range.
•  It can be seen that there is a greater percentage
of INR readings within goal and lesser
percentages of INR readings below or above
goal compared to the above data.
August2014–August2015
•  This data reflects 0.2 below and above the INR
goal range (e.g., 1.8-3.2 for an INR goal of 2-3).
•  This data shows the percent in goal range, the
percent above goal range, and the percent
below goal range for the clinical pharmacist/NPled warfarin management from August 1, 2014
to August 1, 2015.
•  Many clinical studies use an expanded INR goal
range (1.8-3.2) when evaluating percent of INRs
in or out of therapeutic range.
•  It can be seen that there is a greater percentage
of INR readings within goal and lesser
percentages of INR readings below or above
goal compared to the above data.
ClinicalPharmacist/NP-ledWarfarinManagement
N=78
15%
In
13%
Above
72%
Below
•  The warfarin INR management between the PCPled and pharmacist/NP-led groups were similar and
consistent with overall good therapeutic
management in order to reduce embolic events or
bleeding risk
References
1)  Bungard TJ, Gardner L, Archer SL, et al. Evaluation
of a pharmacist-managed anticoagulation clinic:
Improving patient care. Open Med. 2009;3(1):e16e21.
2)  Gupta V, Kogut SJ, Thompson S. Evaluation of
differences in percentage of international
normalized ratios in range between pharmacist-led
and physician-led anticoagulation management
services. J Pharm Pract. 2015 06;28(3):249-55.
3)  Van Walraven C, Jennings A, Oake N, et al. Effect
of studying setting on anticoagulation control: a
systemic review and metaregression. Chest. 2006;
129(5): 1155-1166.