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Anticoagulation program helps keep patients' lab results within range
Pharmacists keep patients motivated
A hospital pharmacy's anticoagulation consultation tool has proven to be an efficient and productive way to improve patient safety.
With the tool, medical staff easily keep track of patients whose International Normalized Ratio (INR) is outside the range and who need intervention.
"We chose this as a project because we're a Joint Commission-accredited establishment, and part of the Joint Commission's 2009 National Patient Safety goal is to improve the safety of using medications, particularly anticoagulants," says Brad Mattke, RPh, an assistant director of pharmacy at Maricopa Integrated Health System in Phoenix, AZ. Mattke is in charge of outpatient pharmacy operations.
Mattke and a pharmacy student on rotation developed the tool, which has been revised several times.
The tool is simple with one page of questions to answer about the patient's medication, nutrient, and herbal intake. The tool's reverse side lists drugs, herbs, and food that impact anticoagulant effects of warfarin. (See sample items from tool.)
The list of drugs, herbs, and food makes it convenient for pharmacists to review when consulting with patients, Mattke notes.
"The whole purpose of this tool is that we do a face-to-face consultation with the patient who is receiving warfarin every time the patient gets his or her medication," he says.
The pharmacists goes through the tool's questions, asking patients for the last time they had their medication refilled and whether they are taking any new prescription medication.
"We walk the patient through the tool and what happens with drug-drug interactions," Mattke explains. "We discuss any changes in the patient's diet and drug-nutrient interactions, including how if they go on a diet it may affect their vitamin K intake and things like that."
If the patient mentions something new, then the pharmacist can flip over the tool and look to see if the patient's new drug is listed on the back and to see what type of impact the drug could have, Mattke says.
Pharmacists also explain to patients how their herbal products might cause a drug-herbal interaction.
"Our population uses herbals a lot, so we ask them whether they've started taking any herbal products since their last refill, and we mention gingko and green tea, which decrease the anticoagulation effect of warfarin," Mattke says.
The tool takes only a few minutes to use once a pharmacist is experienced in using it.
"In December, 2008, we rolled it out across the health system," Mattke says.
The hospital system purchased a software program by Standing Stone Inc. of Westport, CT. The program, called CoagClinic, links the hospital's system to a network that has information about patients' INR data, he says.
"So anyone who would need to verify what the patient's INR is and when it was last drawn could do so," Mattke explains.
"When we receive a warfarin refill or a new prescription, the pharmacist goes into the CoagClinic software program and verifies when and what the last INR value was," he adds. "We check to see that it was within our goal, and our hope is that it has been drawn in the last 30 days."
If the information is old, pharmacists can call patients and remind them that it's time for a lab test.
"Once we do that we document in the patient's profile that we have verified the INR," Mattke says. "And if everything is okay, we'll fill the prescription and then attach the consultation tool."
When pharmacists learn that a patient's lab results are higher than the acceptable range, they'll notify the physician and fax or telephone him the findings, Mattke says.
If the INR results are greater than 5, then the pharmacist will need to speak with the patient's physician before giving the patient the medication, he adds.
"We go over this information with patients to let them know they need to cooperate with the doctor and do whatever the doctor wants in adjusting the medication dose," Mattke says. "What we want to do is work with the patient and doctor and make sure the patient is taken care of and the dose is adjusted."
Mattke's goal is to see a long-term improvement in patients' INR results.
"My goal would be to track this over the next year and trend it and hopefully see that we're going from 40% of patients having INR results within range to 50-70% of patients having results within range," Mattke says. "It'll never be 100%, but how I'd measure the success of this program is by increasing the number of patients within range."
Before starting the program, the lab results went to patients' charts, and the physicians might never have seen them, Mattke notes.
"It would have been up to the physician to look at the results and make changes," he says.
For the more adherent patients, who don't need to be motivated, their regimen would remain the same. But for the less adherent patients, things would change and the patients would need to be re-educated and motivated to improve their adherence, Mattke says.
"Our no-show rate for doctors' office visits is 35-40%, so motivation and getting patients interested in their own care is going to have the biggest impact on their health outcomes," he adds. "Talking to these patients and taking an interest in their care might encourage them to take more interest in their own care and treatment."
Pharmacists also update patients' prescription changes in the software so these can be tracked.
"For patients who continue to have higher or lower results, we continue to work with the doctor and continue to let him know if the patient's condition is not being controlled," Mattke explains.
Pharmacists also try to determine why a particular patient is not adherent with treatment.
It could be that the patient was on vacation and forgot to bring his medication along. So the pharmacist would note that the patient missed doses and have a talk with the patient about adherence.
"The pharmacists educate them about the importance of not missing doses and about what they should do if they do miss a dose," Mattke says.
"For example, if it's time for their next dose after they've missed one, then they should just take that dose," he adds. "But if they were supposed to take their dose in the morning and now it's 5 p.m., then they should go ahead and take the dose, but get back on the regular schedule the next morning."
Pharmacists, using the tool, also inquire about adverse drug reactions.
"We ask if the patient has had any signs of bleeding, like nose bleeds, bleeding gums, signs of clotting, vision problems, leg pain, and chest pain," Mattke says.
The ultimate aim of having pharmacists use the tool to help track patients' progress is to provide patients with treatment adherence reinforcement at the times when they pick up their prescription refills, Mattke notes.
"They will refill their prescriptions each month, but they might see their doctor only once every three or four months," he adds. "So this gives us a great opportunity to maintain a relationship and try to keep these patients motivated."