Development of Pharmacist-managed Warfarin Therapy at Mahosot Hospital, Lao PDR

Abstract

The objective of this study was to develop pharmacist-managed warfarin therapy at Mahosot Hospital. The study was a mixed-method research including qualitative interviews and experimental study. The duration of the study was carried out between January and May 2019. Descriptive statistics and a content analysis were used for qualitative interviews. A student t-test, a Mann-Whitney U test, a repeated-measure ANOVA test, a Chi-squared test, a Fisher’s exact test and a Cochran’s test were implemented for statistical analysis. Measuring clinical outcomes as efficacy outcomes were: 1) time in therapeutic range (TTR) 2) INR 3) knowledge scores 4) DRPs (sub-therapeutic dosage, over dosage, and drug interactions) 5) thromboembolism events 6) patient adherences, and safety outcome was: 1) adverse drug reactions (major bleeding or minor bleeding). Qualitative interviews were face-to-face and focus group interviews. The face-to-face interviews was based on 9 healthcare professionals: 3 doctors, 3 nurses, and 3 pharmacists. The major themes emerged from the interviews consisted of healthcare professionals’ experiences of current practice problems with warfarin therapy, healthcare professionals’ perspectives on ways to improve services, and healthcare professionals’ educations and training. The focus group interview was interviewed 8 healthcare professionals included 2 doctors, 3 nurses, and 3 pharmacists. The major themes were the collaborations among healthcare professionals, expectations of pharmacists’ roles by healthcare professionals, and development of training program for healthcare professionals. The results from the qualitative interviews were used to develop the intervention of RCT study, called “pharmacist-managed warfarin therapy”. The study was compared between 36 patients from the intervention group and 36 patients from the control group (usual care). Patients' mean age was 53.1 ± 14.6 and 50.8 ± 14.0 years old of the intervention and control group. There was 63.3 ± 35.5 % of time in therapeutic range (TTR) in the intervention group which higher than 45.3 ± 39.9 % of TTR in the control group, with statistically significant difference (p-value = 0.046). The percentage of patients’ INR value in therapeutic range in the intervention group was higher than the percentage of patient in the control group (73.7 % with 61.7 %, respectively). There was statistically significant difference of patients’ knowledge score between the intervention and control group at third visit (13.2 ± 1.4 and 7.0 ± 3.6, p-value = 0.013). Twenty DRPs found in 16 patients in the intervention group at baseline visit. The most type of DRPs from 4 visits were sub-therapeutic dosage. Doctors and patients accepted drug-related problems (DRPs) and solved the problem at baseline to third visits 60.0 %, 33.3 %, 25.0 % and 16.7 % of DRPs in the intervention group. No events of thromboembolism and major bleeding were found. Patients’ adherence were assessed by the Morisky, Green, and Levine (MGL) questionnaire 4-items scale. The highest adherence was 100.0 % and the lowest was 69.4 %. Mean percentage of pill count in the intervention group was 87.3 ± 16.9 % higher than 81.8 ± 15.7 % of patient in the control group, with no significant difference. Minor bleeding events were presented as bruising, nose bleeding, gum bleeding, and bleeding in stool. Almost 6 cases in 6 patients presented a minor bleeding in the intervention group and 9 cases in 9 patients in the control group.

Conclusion: Time in therapeutic range in the intervention group was statistically significant higher than in the control group. Pharmacist-managed warfarin therapy was developed by healthcare professionals could use it in the future when anticoagulant clinic is establishing.

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