Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P = 0.393) and adverse events [major bleeding events (0 vs. 1.2%, P = 1.000), minor bleeding events (10.0 vs. 9.8%, P = 0.960), thromboembolic events (0 vs. 0%, P = 1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P = 1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P = 1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P = 0.148), and extreme total (8.4 vs. 5.8%, P = 0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P = 0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P = 0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.
Anticoagulants China International normalized ratio Pharmacists Telemedicine Warfarin
This is a preview of subscription content, log in to check access.
We would like to thank Wang CH for helpful comments.
This research was funded by the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry [Grant Number: 2015B001]; the Fujian Medical Innovation Project [Grant Number: 2014-CX-18] and the Natural Science Foundation of Fujian Province of China [Grant Number: 2015Y0020].
Conflicts of interest
The authors declare that they have no conflicts of interest.
Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: chest guideline and expert panel report. Chest. 2016;149(2):315–52.CrossRefGoogle Scholar
Downing A, Mortimer M, Hiers J. Impact of a pharmacist-driven warfarin management protocol on achieving therapeutic international normalized ratios. Am J Health Syst Pharm. 2016;73:69–73.CrossRefGoogle Scholar
Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e152–84. https://doi.org/10.2146/sp150039.CrossRefGoogle Scholar
Biscup-Horn PJ, Streiff MB, Ulbrich TR, Nesbit TW, Shermock KM. Impact of an inpatient anticoagulation management service on clinical outcomes. Ann Pharmacother. 2008;42:777–82.CrossRefGoogle Scholar
Chau T, Rotbard M, King S, Li MM, Leong WA. Implementation and evaluation of a warfarin dosing service for rehabilitation medicine: report from a pilot project. Can J Hosp Pharm. 2006;59:136–47.Google Scholar
Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med. 1998;158:1641–7.CrossRefGoogle Scholar
Wallvik J, Sjalander A, Johansson L, Bjuhr O, Jansson JH. Bleeding complications during warfarin treatment in primary healthcare centres compared with anticoagulation clinics. Scand J Prim Health Care. 2007;25:123–8.CrossRefGoogle Scholar
Cryder BT, Felczak MA, Darkwa A, Patel H, Janociak JD, Rihani R. Transition of stable patients from traditional anticoagulation clinic services to telephonic management. Int J Clin Pharm. 2017;39:569–72.CrossRefGoogle Scholar
Lee JC, Horner KE, Krummel ML, McDanel DL. Clinical and financial outcomes evaluation of multimodal pharmacist warfarin management of a statewide urban and rural population. J Pharm Pract. 2018;31(2):150–6.CrossRefGoogle Scholar
Prochaska JH, Göbel S, Keller K, Coldewey M, Ullmann A, Lamparter H, et al. Quality of oral anticoagulation with phenprocoumon in regular medical care and its potential for improvement in a telemedicine-based coagulation service-results from the prospective, multi-center, observational cohort study thrombEVAL. BMC Med. 2015;13:14.CrossRefGoogle Scholar
McCahon D, Baker JM, Murray ET, Fitzmaurice DA. Assessing the utility of an online registry for patients monitoring their own warfarin therapy. J Clin Pathol. 2016;69:331–6.CrossRefGoogle Scholar
Wittkowsky AK, Nutescu EA, Blackburn J, Mullins J, Hardman J, Mitchell J, et al. Outcomes of oral anticoagulant therapy managed by telephone vs in-office visits in an anticoagulation clinic settings. Chest. 2006;130:1385–9.CrossRefGoogle Scholar
Stoudenmire LG, DeRemer CE, Elewa H. Telephone versus office-based management of warfarin: impact on international normalized ratios and outcomes. Int J Hematol. 2014;100:119–24.CrossRefGoogle Scholar
Ryan F, Byrne S, O’Shea S. Randomized controlled trial of supervised patient self-testing of warfarin therapy using an online consulting-based expert system. J Thromb Haemost. 2009;7:1284–90.CrossRefGoogle Scholar
Hassan S, Naboush A, Radbel J, Asaad R, Alkaied H, Demissie S, et al. Telephone-based anticoagulation management in the homebound setting: a retrospective observational study. Int J Gen Med. 2013;6:869–75.CrossRefGoogle Scholar
Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127:1515–22.CrossRefGoogle Scholar
Chan FW, Wong RS, Lau WH, Chan TY, Cheng G, You JH. Management of Chinese patients on warfarin therapy in two models of anticoagulation service—a prospective randomized trial. Br J Clin Pharmacol. 2006;62:601–9.CrossRefGoogle Scholar
Ahmed NO, Osman B, Abdelhai YM, El-Hadiyah TMH. Impact of clinical pharmacist intervention in anticoagulation clinic in Sudan. Int J Clin Pharm. 2017;39(4):769–73.CrossRefGoogle Scholar
Faircloth JM, Miner KM, Alsaied T, Nelson N, Ciambarella J, Mizuno T, et al. Time in therapeutic range as a marker for thrombotic and bleeding outcomes in Fontan patients. J Thromb Thrombolysis. 2017;44:38–47.CrossRefGoogle Scholar
Zhang J, Liu M, Chen Q, Wu J, Cao H. Outcomes of an online pharmacist-managed anticoagulation clinic for individuals on warfarin therapy living in rural communities. Thromb Res. 2017;157:136–8.CrossRefGoogle Scholar
Chan FW, Wong RS, Lau WH, Chan TY, Cheng G, You JH. Management of Chinese patients on warfarin therapy in two models of anticoagulation service—a prospective randomized trial. Br J Clin Pharmacol. 2006;62(5):601–9.CrossRefGoogle Scholar
Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost. 1993;69:236–9.CrossRefGoogle Scholar
Schulman S, Kearon C. Subcommittee on control of anticoagulation of the scientific and standardization committee of the international society on thrombosis and haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. Thromb Haemost. 2005;3:692–4.CrossRefGoogle Scholar
Boman K, Davidson T, Gustavsson M, Olofsson M, Renström GB, Johansson L. Telemedicine improves the monitoring process in anticoagulant treatment. J Telemed Telecare. 2012;18:312–6.CrossRefGoogle Scholar