Warfarin patients thrive under anticoagulation management service

Patients taking the blood-thinning medication warfarin have fewer complications when managed by a specialized anticoagulation service than do those who receive usual care from their physicians. That was a finding of a study conducted by Kaiser Permanente's Clinical Pharmacy Anticoagulation Service.

The study included a total of 6,645 mostly elderly patients needing warfarin to maintain vascular health. Clinical pharmacists using specialized knowledge of anticoagulants and a computerized patient tracking system from 4S Systems Ltd. closely monitored the intensity of patients' blood thinning, reminded patients to return for important lab tests, and provided intensive education to patients receiving warfarin.

"Only about 25% of all patients taking warfarin in the United States are managed by some type of formalized anticoagulation management service," said Dan Witt, Pharm.D., manager of clinical pharmacy services for Kaiser Permanente of Colorado. "This study shows that when a focused group of pharmacy experts are allowed to partner with their physician colleagues to closely monitor this highly sensitive drug, a patient's risk of experiencing complications from warfarin is greatly reduced."

"One of the important things about the study is that it included far more patients than any other study has," said Witt. "Also, the control group that the pharmacist group was compared with consisted of physicians who were relatively experienced and were already doing a good job of managing anticoagulation therapy. The control group as a whole was very strong."

The service evaluated in the study was provided almost exclusively by phone or mail as opposed to face-to-face interaction between patient and provider. "Most of the studies up to now have looked at face-to-face management," said Witt. "There's been a running debate among those who do anticoagulation management that phone care is not as good and is potentially dangerous because you don't have the face-to-face interaction. This study is important in that it shows that you can achieve very good outcomes if you have systems in place to facilitate providing care via phone or mail. A lot of people do that, and now they have the validation that it can be an effective practice."

Witt also stressed that face-to-face interaction with patients is still a necessary practice in certain cases, but that having the option of treating the patient via the phone is also important. "A face-to-face operation just may not be feasible based on the number of people you have to work with," he said.

Another key area of the anticoagulation management service highlighted in the study centered on the education provided to patients receiving warfarin. Here, the results showed fewer therapy-related complications. "It's really important for patients taking a medication like this, where so many things they do in their lives have potential impact, that they have a good understanding about that," said Witt. "One reason we saw good outcomes is that we spent a lot of time working with the patients individually and teaching them about their medication."

The Kaiser program taps the expertise of 16 clinical pharmacists who monitor more than 6,500 patients taking warfarin. In the program, R.Ph.s work with the same group of patients, thereby becoming familiar with their habits, risks, and so on. The pharmacists help devise a plan to guide the patients through the process and, by doing so, minimize the risk of complications.

"Probably the most important thing we can teach patients is 'If you have questions, call,'" said Witt. "One of the nice things about the Kaiser system is that it's an integrated system, so the pharmacy system and the medical records system are contained in the same area. So drug interaction information is easily transferable from the place where the drugs were dispensed or prescribed to the anticoagulation service."