Results of a pharmacist-managed anticoagulation service at a long-term care facility

Purpose: To compare warfarin therapy managed by physicians to a pharmacist-managed anticoagulation service in a long-term care facility (LTCF).  The impact of oral anticoagulation monitoring by pharmacists in a LTCF has not been studied.

Methods: Patients receiving warfarin at a LTCF were identified. INRs were monitored and warfarin dosages were adjusted at the discretion of the pharmacist. After four years, a retrospective chart review was conducted. Patients were included if they were anticoagulated for a minimum of 1 month and had at least 2 INR values.   Information on demographics, indication for and length of warfarin therapy, INR values, time in therapeutic range, drug interactions, and thromboembolic and bleeding events were recorded.  

Results: A total of 316 patients met our inclusion criteria.  The post-pharmacist TTR was 64% compared to 29% before intervention.  The extended TTR (goal INR +/- 0.2) was 76% post-pharmacist intervention and 43% prior to the intervention.  Before pharmacist intervention 47% of INRs were less than 2 and 2% were greater than 4, compared to 24% of INRs less than 2 and 1% greater than 4 following intervention. No adverse events were reported.  

Conclusion: Although there were limitations to this retrospective analysis, the results of this study demonstrate that a clinical pharmacist does improve the management of anticoagulation therapy by increasing the TTR and decreasing supra and subtherapeutic INRs.  The clinical pharmacist provides a consistent approach to anticoagulation management, and is an asset that should be utilized in caring for patients in LTCF.