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Dr : Osama Badry Cardiology /Anticogaulation Coordinator Incharge of Anticoagulation Service AWH-HMC/Qatar

“ The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine. (2001). National Academy Press “ The provision of the necessary health care service to the appropriate person at appropriate time, and using the best means with the objectives of getting the best results for each individual patient, and the community at large.” Qatar Supreme Council of Health

Quality of Care

Scientific Knowledge

Effective Patient centered

Patients’ Needs Waiting Time

Timely Efficient

Wasteful Practices

Warfarin : Effective rat poison

Warfarin Therapy

 Warfarin –Most widely used vitamin K antagonists(VKAs) worldwide in the prevention of treatment of blood clots. it’s used complicated by various factors Ansell J .et.al 2004,Bungard TJ,et.al.2009,Hamby L ,et.al 2000  Utilizing the correct intensity and maintaining the patient in the therapeutic-determinant of its therapeutic effectiveness and safety Ansell J .et.al 2004,Yi W.et.al.2008,kamali F.et.al,2010  3 primary models available for managing oral anticoagulant care are usual medical care, anticoagulation clinic, patient self management Wilson SJ.et.al 2003

Question

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Is the pharmacist managed anticoagulation more effective than usual care?

Anticoagulation Clinic (AC)

 Anticoagulation management services(AMSs) (i.e.; anticoagulation clinics) is accepted as gold standard and one of the approaches to improve anti Coagulant care  Ansell J et al. 2001 Pharmacist Managed AMS in comparison to other clinics (physician / Nurses) :   Achieve superior anticoagulation control Favorable impact on hospitalization Ruud KM. et al. 2010

Pharmacist Managed AC

 Pharmacist-staffed Acs provided patient education, a more consistent monitoring and early recognition of risk factors.

Chamberlain MA. et.al .2001

 Pharmacist –managed AC service demonstrated decreased advers events(39-47 % bleeding) and reduced hospital costs (USD 375 1620 per patient).

Saokaew S .2010, You JHS CA.et al .2008

Quality Team

         No systematic approach for tracking and scheduling INRs.

No specific dosing nomogram or protocol are utilized ; only individual physician knowledge and experience with management of warfarin is utilized. Patients who are not getting their lab work done routinely may not discovered until a doctor’s appointment or a prescription renewal. Long waiting time resulted in patient’ frustration and low satisfaction. No structured education or counseling for patients and/or their families.

Unavailability of the treating physicians. No active participation for other health care providers e.g. Pharmacists, Patient educators and dieticians. Follow-up appointment depends on physician’s scheduling.

No structured evaluation of service e.g non adherence to warfarin therapy.

 Conclusion: The pharmacist-managed anticoagulation program within a family practice clinic compared to usual care by the physicians achieved significantly better INR control as measured by the percentage of time patients’ INR values were kept in both the therapeutic and expanded range. Based on the results of this study, a collaborative family practice clinic using pharmacists and physicians may be an effective model for anticoagulation management with these results verified in future prospective randomized studies.

Impact of PDAS on Quality and Safety of HIT Management

Outcome with pharmacist – and physician managed warfarin mediated anticoagulation

Efficacy with pharmacist –managed in-hospital anticoagulation

Garwood et al 2008

Process of implementation

Senior Executive Pharmacy & Therapeutic Committee Multdisciplinary Subcommittee Cardiology Champion Pharmacy Director Idea

Challenges

Resources Physician resistance Patient satisfaction Referral and first appointment

Anticoagulation clinic statistics Total Number of Patients May 2013- September 2014

Indication AF MVR AVR DVR L-V thrombus Pulmonary hypertension DVT Pulmonary Embolism Portal vein thrombosis Stroke APS Sever AS,MR Right portal vein thrombosis Post MI , LV aneurysm IVC Low EF Cerebral vein thrombosis Total No 59 9 8 5 7 2 38 1 1 1 1 2 171 28 2 3 3 1

May /2013 June/2013 July/2013 August /2013 September/2013 October/2013 November/2013 December/2013 JANUARY /2014 February /2014 March/2014 April/2014 May/2014 June/2014 July/2014 August/2014 September/2014

Month No

11 47 79 50 85 53 74 96 86 105 101 98 97 95 104 106 123

Interventions

 Research done in collaboration with Qatar university, life of patients attending an ambulatory pharmacist-managed anticoagulation clinic in Qatar’’, see the supporting evidence.

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Satisfaction and quality of  The quantitative improvement was done by calculation of TTR (time in therapeutic range) a metric of how well patients are managed on warfarin therapy by using software program, the result is 77.8 Another two ongoing researches were accepted by research center  1-‘’evaluation of clinical and economical outcomes at pharmacist versus physicians –based anticoagulation outpatient clinic and its impact on the cardiovascular disease management in Qatar””  2-‘’ The Effect of Genetic Variants on Warfarin Dosing and Its Impact on Cardiovascular Outcomes in Qatar’’

Why We Are Successful

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Strong and effective leadership

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Multidisciplinary Team Quality Improvement

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First clinic run by a clinical pharmacist in HMC/ QATAR

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Progress does not involve replacing one theory that is wrong with one that is right, rather it involves replacing one theory that is wrong with one that is more subtly wrong.

Hawkins Law