Improving outpatient warfarin use for hospitalized patients with atrial fibrillation

  • Daniel R. Touchette
  • Margaret E. McGuinness
  • Steve Stoner
  • David Shute
  • Jennifer M. Edwards
  • Kathy Ketchum
Keywords: Pharmacists, Anticoagulants, Atrial Fibrillation, United States

Abstract

Atrial fibrillation affects an estimated 5 million Americans and accounts for approximately 15% of all strokes. Few studies have successfully addressed patient screening, assessment, and introduction of appropriate antithrombotic therapy in patients with atrial fibrillation.

Objective: To assess whether an intervention improved planned antithrombotic prescribing at the time of discharge in hospitalized patients.

Methods:  The study was a prospectively designed, retrospectively evaluated, non-blinded, historical control study of a pharmacist-initiated intervention. The intervention, consisting of pharmacist review and assessment of antithrombotic prescribing in patients with non-valvular atrial fibrillation, was conducted in an urban teaching hospital.

Results: Although antithrombotic prescribing was not significantly higher at discharge in the 252 enrolled subjects (control 67.3% vs. intervention 70.8%; p = 0.58), a significantly greater number of patients had a written discharge plan for antithrombotic therapy (control 73.5% vs. intervention 88.3%; p < 0.01). The adjusted odds ratio that the study group was associated with an improvement in planned or actual warfarin use was 2.46 (95% CI 1.63-3.74). In addition, clinicians adhered to guidelines for antithrombotic therapy in patients with atrial fibrillation more frequently in the intervention group (control 70.4% vs. intervention 88.2%; p < 0.01).

Conclusion:  A program designed to identify hospitalized patients with non-valvular atrial fibrillation, assess their need for stroke prophylaxis, and initiate appropriate antithrombotic therapy led to an increase in planned antithrombotic, and most importantly, warfarin use upon discharge from the hospital. Confirmation that an increase in planned antithrombotic use upon discharge results in an actual increase in use after discharge is needed to determine the true effectiveness of this intervention.

Downloads

Download data is not yet available.

References

1. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, Seward JB, Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006;114(2):119-25.

2. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D'Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ.Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 2004;110(9):1042-6.

3. Fang MC, Singer DE, Chang Y, Hylek EM, Henault LE, Jensvold NG, Go AS. Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) study. Circulation 2005;112(12):1687-91.

4. Go AS. Efficacy of anticoagulation for stroke prevention and risk stratification in atrial fibrillation: translating trials into clinical practice. Am J Manag Care 2004;10(3 Suppl):S58-65.

5. Atwood JE, Albers GW. Anticoagulation and atrial fibrillation. Herz 1993;18(1):27-38.

6. Albers GW, Sherman DG, Gress DR, Paulseth JE, Petersen P. Stroke prevention in nonvalvular atrial fibrillation: a review of prospective randomized trials. Ann Neurol. 1991;30(4):511-8.

7. Albers GW, Dalen JE, Laupacis A, Manning WJ, Petersen P, Singer DE. Antithrombotic therapy in atrial fibrillation. Chest 2001;119(1 Suppl):194S-206S.

8. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22(8):983-8.

9. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999;131(7):492-501.

10. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994;154(13):1449-57.

11. Currie CJ, Jones M, Goodfellow J, McEwan P, Morgan CL, Emmas C, Peters JR. Evaluation of survival and ischaemic and thromboembolic event rates in patients with non-valvar atrial fibrillation in the general population when treated and untreated with warfarin. Heart 2006;92(2):196-200.

12. Vemmos KN, Tsivgoulis G, Spengos K, Manios E, Toumanidis S, Zakopoulos N, Moulopoulos SD. Anticoagulation influences long-term outcome in patients with nonvalvular atrial fibrillation and severe ischemic stroke. Am J Geriatr Pharmacother. 2004;2(4):265-73.

13. Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):429S-56S.

14. Tapson VF, Hyers TM, Waldo AL, Ballard DJ, Becker RC, Caprini JA, Khetan R, Wittkowsky AK, Colgan KJ, Shillington AC; NABOR (National Anticoagulation Benchmark and Outcomes Report) Steering Committee. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med. 2005;165(13):1458-64.

15. Brass LM, Krumholz HM, Scinto JD, Mathur D, Radford M. Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med. 1998;158(19):2093-100.

16. Brass LM, Krumholz HM, Scinto JM, Radford M. Warfarin use among patients with atrial fibrillation. Stroke 1997;28(12):2382-9.

17. Gage BF, Boechler M, Doggette AL, Fortune G, Flaker GC, Rich MW, Radford MJ. Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. Stroke 2000;31(4):822-7.

18. Gurwitz JH, Monette J, Rochon PA, Eckler MA, Avorn J. Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med. 1997;157(9):978-84.

19. Ruigomez A, Johansson S, Wallander MA, Rodriguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol. 2002;55(4):358-63.

20. Bungard TJ, Ghali WA, McAlister FA, Buchan AM, Cave AJ, Hamilton PG, Mitchell LB, Shuaib A, Teo KK, Tsuyuki RT. Physicians' perceptions of the benefits and risks of warfarin for patients with nonvalvular atrial fibrillation. CMAJ 2001;165(3):301-2.

21. Bungard TJ, Ghali WA, McAlister FA, Buchan AM, Cave AJ, Hamilton PG, Mitchell LB, Shuaib A, Teo KK, Tsuyuki RT. The relative importance of barriers to the prescription of warfarin for nonvalvular atrial fibrillation. Can J Cardiol. 2003;19(3):280-4.

22. Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT. Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med. 2000;160(1):41-6.

23. Kutner M, Nixon G, Silverstone F. Physicians' attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med. 1991;151(10):1950-3.

24. McCrory DC, Matchar DB, Samsa G, Sanders LL, Pritchett EL. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med. 1995;155(3):277-81.

25. Munschauer FE, Priore RL, Hens M, Castilone A. Thromboembolism prophylaxis in chronic atrial fibrillation. Practice patterns in community and tertiary-care hospitals. Stroke 1997;28(1):72-6.

26. Chamberlain MA, Sageser NA, Ruiz D. Comparison of anticoagulation clinic patient outcomes with outcomes from traditional care in a family medicine clinic. J Am Board Fam Pract. 2001;14(1):16-21.

27. Bussey HI, Rospond RM, Quandt CM, Clark GM. The safety and effectiveness of long-term warfarin therapy in an anticoagulation clinic. Pharmacotherapy 1989;9(4):214-9.

28. 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(15):1641-7.

29. Conte RR, Kehoe WA, Nielson N, Lodhia H. Nine-year experience with a pharmacist-managed anticoagulation clinic. Am J Hosp Pharm. 1986;43(10):2460-4.

30. Ellis RF, Stephens MA, Sharp GB. Evaluation of a pharmacy-managed warfarin-monitoring service to coordinate inpatient and outpatient therapy. Am J Hosp Pharm. 1992;49(2):387-94.

31. Garabedian-Ruffalo SM, Gray DR, Sax MJ, Ruffalo RL. Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic. Am J Hosp Pharm. 1985;42(2):304-8.

32. Lee YP, Schommer JC. Effect of a pharmacist-managed anticoagulation clinic on warfarin- related hospital readmissions. Am J Health Syst Pharm 1996;53(13):1580-3.

33. Wilt VM, Gums JG, Ahmed OI, Moore LM. Outcome analysis of a pharmacist-managed anticoagulation service. Pharmacotherapy 1995;15(6):732-9.

34. Locke C, Ravnan SL, Patel R, Uchizono JA. Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service. Pharmacotherapy 2005;25(5):685-9.

35. 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(5):1515-22.

36. Burkiewicz JS. Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy 2005;25(8):1062-7.

37. Samsa GP, Matchar DB, Goldstein LB, Bonito AJ, Lux LJ, Witter DM, Bian J. Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities. Arch Intern Med 2000;160(7):967-73.

38. Bajorek BV, Krass I, Ogle SJ, Duguid MJ, Shenfield GM. Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention. J Am Geriatr Soc 2005;53(11):1912-20.

39. Crotty M, Whitehead C, Rowett D, Halbert J, Weller D, Finucane P, Esterman A. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. BMC Health Serv Res 2004;4(1):6.

40. Elliott RA, Woodward MC, Oborne CA. Antithrombotic prescribing in atrial fibrillation: application of a prescribing indicator and multidisciplinary feedback to improve prescribing. Age Ageing 2002;31(5):391-6.

41. Hobbs FD, Fitzmaurice DA, Mant J, Murray E, Jowett S, Bryan S, Raftery J, Davies M, Lip G. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess 2005;9(40):iii-iv, ix-x, 1-74.

42. Jackson SL, Peterson GM, Vial JH. A community-based educational intervention to improve antithrombotic drug use in atrial fibrillation. Ann Pharmacother 2004;38(11):1794-9.

43. Maeda K, Shimbo T, Fukui T. Cost-effectiveness of a community-based screening programme for chronic atrial fibrillation in Japan. J Med Screen 2004;11(2):97-102.

44. Morgan S, Mant D. Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Br J Gen Pract 2002;52(478):373-4, 7-80.

45. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: John Wiley & Sons, Inc.; 2000.

46. Caro JJ. An economic model of stroke in atrial fibrillation: the cost of suboptimal oral anticoagulation. Am J Manag Care 2004;10(14 Suppl):S451-58; discussion S8-61.

47. Swancutt D, Hobbs R, Fitzmaurice D, Mant J, Murray E, Jowett S, Raftery J, Bryan S, Davies M, Lip G. A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732]. BMC Cardiovasc Disord 2004;4:12.

48. Wittkowsky AK. Effective anticoagulation therapy: defining the gap between clinical studies and clinical practice. Am J Manag Care 2004;10(10 Suppl):S297-306; discussion S12-7.

49. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166(5):565-71.

50. Glasgow RE, Magid DJ, Beck A, Ritzwoller D, Estabrooks PA. Practical clinical trials for translating research to practice: design and measurement recommendations. Med Care 2005;43(6):551-7.

51. Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 2003;290(12):1624-32.
Published
2008-03-10
How to Cite
1.
Touchette DR, McGuinness ME, Stoner S, Shute D, Edwards JM, Ketchum K. Improving outpatient warfarin use for hospitalized patients with atrial fibrillation. Pharm Pract (Granada) [Internet]. 2008Mar.10 [cited 2019Jun.27];6(1):43-0. Available from: https://www.pharmacypractice.org/journal/index.php/pp/article/view/233
Section
Original Research