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In an Anticoagulation Clinic, Unrelated Interventions Abound

Melanie Boros, Pharm.D., BCPS, meets with a patient at Cleveland Clinic Akron General’s outpatient anticoagulation clinic.

IT’S WELL KNOWN that when pharmacists guide anticoagulation treatment, patient outcomes are better. International normalized ratio (INR) levels are within the target range more of the timeⁱ and hemorrhage rates are lowerⁱⁱ, compared to the usual care.

But what about the care pharmacists provide in anticoagulation clinics that is not directly related to the primary purpose of the visit?

A new study published in AJHP found that pharmacists offer significant additional care outside the purview of anticoagulation by helping patients avoid adverse events and receive timely treatment for other health concerns, and by improving their continuity of careⁱⁱⁱ.

Med Rec Reveals Important Picture of Patient Health

Michael Hicho, Pharm.D., BCPS

“Pharmacists, whether they’re in the anticoagulation clinic or in any other setting, can make a significant positive impact on patients’ care if they take advantage of each interaction they have with a patient,” said primary author Michael Hicho, Pharm.D., BCPS, who was a PGY1 pharmacy practice resident at Akron General Medical Center, Akron, Ohio, at the time of the study. Dr. Hicho is currently Inpatient Clinical Manager, Pharmacy Service, at Louis Stokes Cleveland VA Medical Center, Cleveland.

“As our findings show, these interactions may not necessarily always involve starting, stopping, or adjusting a medication but can, for example, include collaboration with other healthcare providers to ensure that patients are receiving appropriate care,” he said.

Dr. Hicho drew these conclusions from a retrospective analysis of records from 5,846 pharmacist encounters with 268 patients treated at the Akron General Medical Center’s pharmacist-managed ambulatory anticoagulation clinic between January 2012 and November 2013. The clinic served patients referred by 30 physicians during the study period.

Dr. Hicho’s team classified interventions not directly related to anticoagulation into six major categories (see TABLE below) and 33 subcategories. They found that pharmacists conducted a striking 2,222 interventions not directly related to patients’ primary reasons for visiting the anticoagulation clinic. Nearly 75% of patients received four or more unrelated interventions and almost 14% received 10 or more of these interventions.

Medication reconciliation was the most common intervention not directly related to anticoagulation. During those interactions, pharmacists identified 1,591 medication list discrepancies, including inaccuracies in the medication list for 89% of these instances.

They also found 107 instances in which a patient was taking his or her medication incorrectly and an additional 74 cases in which there was a possibility a patient may have been taking his or her medication incorrectly.

The Continuity of Care Equation

According to Dr. Hicho, pharmacists helped ensure continuity of care by assessing patients’ overall health, sending physicians medical information they collected, recommending primary care physician follow-up, and, in some cases, calling a physician for an immediate onsite visit or urging patients to visit the emergency department.

Amy Rybarczyk, Pharm.D., BCPS

Measuring the clinical and financial value of interventions like these is difficult, said co-author Amy Rybarczyk, Pharm.D., BCPS, Pharmacotherapy Specialist in Internal Medicine, Cleveland Clinic Akron General. “At the moment, there is no standardized method for quantifying pharmacist interventions,” said Dr. Rybarczyk, who was Dr. Hicho’s research advisor at the time of the study. “It’s hard to measure the value of ensuring that a patient gets an antibiotic for a diabetic foot infection that is detected by a pharmacist, for example. A tool like that would be beneficial for our profession to have.”

Collaborative Practice Agreement Buoyed by Findings

The team’s results were so impressive that they were included in a letter to the Ohio Legislature in support of House Bill 188, which called for an expansion of pharmacists’ services as part of collaborative practice agreements. The legislation passed in December 2015.

“We believe the comprehensive care provided to patients in our disease state management clinic helped in this effort to expand pharmacists’ clinical services,” explained Dr. Rybarczyk.

“We believe the comprehensive care provided to patients in our disease state management clinic helped in this effort to expand pharmacists’ clinical services.” — Amy Rybarczyk, Pharm.D., BCPS

Co-author Melanie Boros, Pharm.D., BCPS, Pharmacotherapy Specialist in Internal Medicine at Cleveland Clinic Akron General and Dr. Hicho’s research advisor at the time of study, suggested that one of the important takeaway messages is the trust that patients place in their pharmacists. “When we see a patient with a therapeutic INR, and there are no changes that need to be made to his or her anticoagulation regimen, we can still make a significant impact by simply clarifying what their dose of insulin should be or teaching them about appropriate use of nonprescription medicines, for example,” she said, adding that pharmacists are well-positioned to answer patients’ questions and proactively identify other health issues.

“Like our entire department, pharmacists in the clinic have always made it a priority to care for the whole patient,” she emphasized.

–By David Wild

ⁱ J Throm Thrombolysis 2011; 32:426-430
ⁱⁱ Pharmacotherapy 195; 15:732-739
ⁱⁱⁱ AJHP Residents Issue 2016; 73 (Supp 3):S80-87