A Pharmacist-Led Point-of-Care INR Clinic: Optimizing Care in a Family Health Team Setting

Purpose. Monitoring patients’ international normalized ratio (INR) within a family medicine setting can be challenging. Novel methods of doing this effectively and in a timely manner are important for patient care. The purpose of this study was to determine the effectiveness of a pharmacist-led point-of-care (POC) INR clinic. Methods. At a community-based academic Family Health Team in Toronto, Canada, charts of patients with atrial fibrillation managed by a pharmacist with usual care (bloodtesting at lab and pharmacist follow up of INR by phone) from February 2008 to April 2008 were compared with charts of patients attending a weekly POC INR clinic from February 2010 to April 2010. Time in therapeutic range (TTR) was measured for both groups. Results. 119 patient charts were reviewed and 114 had TTR calculated. After excluding patients with planned inconsistent Coumadin use (20), such as initiating Coumadin treatment or stopping for a surgical procedure, the mean TTR increased from 64.41% to 77.09% with the implementation of the POC clinic. This was a statistically significant difference of 12.68% (CI: 1.18, 24.18; ). Conclusion. A pharmacist-led POC-INR clinic improves control of anticoagulation therapy in patients receiving warfarin and should be considered for implementation in other family medicine settings. 1. Introduction Atrial fibrillation is the most common cardiac dysrhythmia, with a prevalence cited in the literature of 10% in individuals over the age of 80 [1, 2]. Fibrillatory conduction of the atria results in blood stasis, formation of thrombotic clots, and an increased risk of thromboembolic events, such as stroke. Studies have shown that oral anticoagulant therapy, such as warfarin, can help reduce the risk of thromboembolic events by up to 60% compared to those receiving no treatment [3]. Warfarin has a narrow therapeutic range and can also be associated with hemorrhagic side effects, including a known increased risk of gastrointestinal bleeding and hemorrhagic stroke [4]. Regular monitoring of patients on warfarin to maintain levels within therapeutic range is necessary to decrease the incidence of such side effects. This need for continuous monitoring, along with recommendations for an increasing number of patients on warfarin therapy, has led to the development of alternative models for monitoring oral anticoagulant therapy. Traditionally, oral anticoagulation therapy has been monitored by specialists or directly by family physicians, as was the case at the South East Toronto Family Health Team (SETFHT), a community based academic