Transcript IHS Anticoagulation Training Program

Clinical Impact of the IHS
Anticoagulation Training Program
USPHS Scientific and Training Symposium
May 2010
LT Nicholas Sparrow, Pharm.D.
PGY1 Pharmacy Practice Resident
Claremore Indian Hospital
Claremore, Oklahoma
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Disclosure Statement
The opinions expressed in this presentation are
those of the authors and do not necessarily
reflect the views of the Indian Health Service,
Cherokee Nation, or University of Oklahoma
Health Sciences Center.
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Objectives
• Summarize the history and current status of the
Indian Health Service (IHS) Anticoagulation
Training Program (ATP)
• Describe the study design and methods used to
determine the impact of the ATP
• Describe participant perceptions about the impact
of the ATP with respect to:
– Confidence with anticoagulation management
– Development and implementation of anticoagulation clinics
(ACCs) and services
– Anticoagulation clinical practices
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ACCP CHEST Guidelines
Pharmacology and Management of the Vitamin K
Antagonists
“4.1.1. For health-care providers who manage oral
anticoagulation therapy, we recommend that they do
so in a systematic and coordinated fashion,
incorporating patient education, systematic INR
testing, tracking, follow-up, and good patient
communication of results and dosing decisions as
occurs in an anticoagulation management service
(AMS) [Grade 1B].”
Ansell J, et. al. Pharmacology and management of the vitamin K antagonists: ACC EvidenceBased Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):160S-198S.
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IHS Anticoagulation Training Program
History
• Developed in 1999
• Lack of formalized training
– Available programs had limited availability
• George F. Archambault Foundation
– Unrestricted educational grant
• First program offered April 1999
– 5 pharmacists, 1 nurse
– WA, OK, ND, WY, AK, TX
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History
• 3 programs offered in 1999
• Currently offer 4 programs/year
• 351 attendees and 39 programs to date
• 2 year waiting list
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History
124
Attendance by State
67
48
13 12
8
7
6
5
4
3
2
2
2
2
2
2
1
1
1
1
1
1
OK
NM
AZ
AK
MN
TX
SD
OR
WA
ND
MT
ID
WY
KS
MA
MD
MI
MS
NE
FL
IL
KY
NV
TN
WI
18 17
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History
Attendance by Agency
8%
2% 2% 2%
86%
Indian Health Service
Private Sector
Department of Defense
Bureau of Prisons
Other Govt. Agencies
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History
Attendance by Discipline
27
10
2
Pharmacists
Pharmacy Residents
312
Nurses/ARNP
Physicians
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IHS Anticoagulation Training Program
• Interactive, advanced, 3 day training
• Didactic and practical components
Comes Standard
Unique
• Continuing education
• Lecture material and
articles made available
• Didactic lectures
•Direct patient care
•Outcomes database
provided
•Historically, no cost to
participant except
travel
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Anticoagulation Training Program
Clinical Impact Survey
• Co-investigators
– LCDR Ryan Schupbach, Pharm.D., BCPS, CACP
– Michael J. Miller, R.Ph, DrPH – The University of
Oklahoma College of Pharmacy
– Donald Harrison, Ph.D – The University of
Oklahoma College of Pharmacy
• University of Oklahoma counterparts key
in survey design
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Survey Design
• Cross-sectional email survey
• Consent to participate
• Background information
• Evaluate 3 key areas:
– Confidence in anticoagulation management
– Development and implementation of ACCs
– Anticoagulation clinical practices
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Survey Methods
• Pilot phone survey
– Validate survey
– 3 attendees
• 1, 5, 10 years ago
• Modified survey
• Disseminated survey via email
• Collected data over 4 week period
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Study Profile
331 providers trained in
the training program
Exclusions:
-13 ATP Faculty
-2 had previously opted out with the
survey instrument provider
-48 participants with unknown
e-mail addresses
268 participants sent
survey
-1 participant sent survey had not
completed ATP training
-3 started but did not finish survey
-79 did not take survey
185 Surveys
completed
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Results:
Participant Characteristics
Distribution Among ATP Training
Periods
16%
7%
9%
6%
13%
8%
11%
7%
10%
6%
7%
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
97.8% - pharmacists
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Results: Career Progression
ATP Participation
• 55% - Led to responsibility changes
• 76% - Contributed to career progression
Practice Setting
At time of ATP
Currently
Primarily Staffing
45%
21%
Primarily Clinical
26%
34%
Residency/Training
16%
3%
Admin/Management
8%
23%
Other
5%
19%
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Results: Clinic Role
Clinic Role
Response %
Care Provider
26%
Manager
4%
Both
22%
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Miscellaneous Results
• 21% - Helped them develop other clinics
– 48 different clinics
– 13 different specialties
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12
7 specialties
7
4
5
6
5
Smoking Cessation
DM
Asthma
CV Risk Reduction
CKD
Hyperlipidemia
Other
• 98% - Encourage ATP attendance for initial
credentialing
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Results of 1st Aim
Confidence with Anticoagulation Management
• For all statements, >82% agreed / strongly agreed
Highly Rated
• Areas with >60% strongly agreeing
– Educating patients on comprehensive warfarin
management adjustments
– In understanding of warfarin indications
• In anticoagulation management skills overall
– 97% agreed / strongly agreed
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Results of 1st Aim
Confidence with Anticoagulation Management
Areas Needing Improvement
• All areas relating to confidence in outcome
collecting, analyzing, and reporting
• Anticoagulation-related care improved
overall in our ACC
–
–
–
–
3% disagreed / strongly disagreed
12% neutral
39% agreed
45% strongly agreed
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Results of 2nd Aim
Development of Anticoagulation Clinics
62% had ACC at facility at time of ATP attendance
New outpatient
ACC or service
ACC established before ATP?
YES
NO
Developed
5%
62%
Implemented
11%
53%
Improved
80%
37%
New inpatient
ACC or service
ACC established before ATP?
YES
NO
Developed
11%
18%
Implemented
16%
19%
Improved
27%
15%
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Results of 2nd Aim
Development of Anticoagulation Clinics
Three most common barriers
• 33% - Cost of dedicated personnel
• 39% - Office Space
• 47% - Lack of reimbursement
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Results of 3rd Aim
Anticoagulation Clinical Practices
Integrate ACC outcomes ACC demonstrated improvement in
outcomes since ATP attendance
into performance
improvement
YES
NO
Don’t know
Yes
72%
2%
26%
No
25%
31%
44%
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Conclusions
• 98% recommended ATP for initial
credentialing
• 97% felt confidence in anticoagulation
management improved
• 84% felt the anticoagulation management in
their clinics improved
• ATP helped in the development of other
disease management clinics
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Conclusions
• Those without an ACC developed rather than
improved their ACC
• The majority of barriers to ACC implementation
are financially related
• Those who integrated ACC outcomes into
performance improvement were more likely to
report improvement in ACC outcomes
• ATP needs to work on emphasizing outcomes
collection and analysis
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Survey Weaknesses
• Recall bias
– some attended over 10 years ago
• Most ATP faculty involved in ACCs
• Unable to survey 15% of trainees who met
inclusion criteria
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Survey Strengths
• Good representation from each time period
• High response rate
– 70% sent survey, completed it
• 57% of all trainees completed survey
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Clinical Training Programs
• The ATP was created to fill a need
• Many software training programs
• Not many clinical training programs
• Well established program?
– Why not create a training program?
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Thank You!
Nicholas Sparrow, Pharm.D.
PGY1 Pharmacy Practice Resident
Claremore Indian Hospital
[email protected]
918-342-6657
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