COMMUNITY PHARMACY WARFARIN SERVICE Cmmunity Pharmacy Anti-cagulatin Management (CPAM) Service Intrductin INFORMATION FOR GENERAL PRACTICE In cuntries such as the UK, Australia, Canada and USA anticagulant management services are prvided by pharmacists and are successful in achieving a high standard f care. In 2010/11 16 pharmacies, 52 medical centres and ver 600 patients were invlved in a Cmmunity Pharmacy Anti-cagulatin Management (CPAM) Service pilt undertaken by Health Wrkfrce NZ in cllabratin with the Pharmaceutical Sciety f NZ and the New Zealand Cllege f Pharmacists. The pilt prved very successful with patients INR managed in range 80% f the time, and ver 80% cmpliance with appintments. Appendix One prvides a summary f the results. In 2012 the service was rlled ut t 60 new pharmacies, making a ttal f 76 pharmacies nw prviding this service. Additinal pharmacies will be recruited in 2013 and 2014. Overview - What des the Cmmunity Pharmacy Warfarin Service invlve? Cmmunity Pharmacy Warfarin Services are the prvisin f INR pint-f-care testing by accredited cmmunity pharmacists. Fllwing a finger prick sample f bld analysed in a machine t determine the INR result, the pharmacist adjusts the next dse f warfarin accrding t agreed Standing Orders and an apprved n-line cmputer decisin-supprt system which calculates the dse and date f the next test. Similar t finger prick testing fr bld glucse, the test result is available within minutes and the patient receives printed treatment advice immediately n the dse they shuld take. The GP is autmatically infrmed f each test and the recmmended dse. Hw des the Service wrk? 1. The GP refers the patient t the service. 2. The patient s INR is tested using a finger-prick sample f bld placed n a test strip and analysed in a small prtable device. The INR Online sftware autmatically prvides the result and calculates a recmmended dse. 3. The pharmacist reviews the result, prvides advice n the dse and date f the next test, and prints ut a small dsing calendar fr the patient t take away. 4. The INR result is autmatically sent t the PMS Prvider Inbx. In additin, the GP is alerted by email f any results utside the set range f 1.5 4. Using this infrmatin the GP has the pprtunity t adjust the suggested dse and date f the next test. 5. Patients are able t return t care by the GP at any time. Patients with pr cntrl r pr cmpliance may be referred back t their GP. DHB Shared Services 0 4 8 0 3 3 9 4 0 A natinal arm f TAS P O B x 5 5 3 5 natinalffice@dhb shared services.h ealth.nz W e l l i n g t n 6 0 1 1
The key pints are: - The Cmmunity Pharmacy Warfarin Service is an integrated patient care mdel. The pharmacist and GP are wrking cllabratively fr the benefit f the patient, and as integral members f the primary health care team. - The pharmacist is wrking under agreed Standing Orders frm the GP, and the GP retains respnsibility fr the patient. - Pharmacists are skilled in medicatin management, and this service is within their scpe f practice. - The GP is infrmed immediately f all INR results and dses, and has the pprtunity t suggest an alternative dsing regime t that recmmended by the decisin supprt system. Results sent t the Prvider In-Bx (and als t TestSafe) The way in which results are sent t the practice is the same way the practice receives results frm the labratry. That is, all test results are sent t the supervising dctr as HL7 messages via HealthLink t the PMS Prvider Inbx, and s infrmatin is able t be upladed int the patient s file as per usual. In Auckland and Christchurch the results als g t the lcal data repsitry, TestSafe. What are the benefits? Benefits fr patients Patients invlved - Immediate infrmatin and advice - Patients really appreciate being able t view their results n the cmputer screen, and graphs shwing prgress. Cnvenience and acceptability - The test invlves a finger prick sample f bld (patients really like this!) - A dsing calendar is prvided t take away - Able t receive autmatic e-mail reminders when their next test is due - Can access their wn results via the internet Health benefits (Refer t Appendix 1) - Increased cmpliance and cntrl - Reduced cmplicatins / adverse events The patients we are testing LOVE it It is three mnths since we started. All f ur patients are nw staying within their target area and are way mre cmpliant than with (testing by) the Labratry Benefits fr GPs and pharmacists The delivery f patient-centred care The service is cnvenient and highly acceptable t patients and has imprtant health benefits Cllabratin and multi-disciplinary team invlvement Utilisatin f the pharmacist s skills in medicines management Practice staff time is freed up Experience shws that nce GPs and practice nurses see first-hand hw the service wrks, they are very supprtive.
The dctr retains verall respnsibility The GP retains verall respnsibility fr the patient. The pharmacist is wrking under agreed Standing Orders frm the GP this enables the pharmacist t make warfarin dse adjustments accrding t the INR test result. The GP is alerted (and his/her advice sught) if the INR results are utside the specified safe range. Gd cntrl reduces cmplicatins Warfarin is regarded as a high risk medicine, but cmplicatins are reduced if the patient stays within the therapeutic treatment range (TTR). The immediacy f infrmatin abut the INR result and dse f warfarin assists with cmpliance. The INR Online Tl uses cmputer decisin supprt sftware. When cmpared t manual dsing, cmputer-assisted dsing has been shwn t increase the time that patients INRs are within the target range, and therefre has the ptential t significantly reduce the risk f bleeding and thrmbemblic events 1. If I agree t take part, d I need t refer all my patients? General practice can wrk with the pharmacy t identify patients suitable fr the service. It is likely there will still be patients wh will need t cntinue t be managed by the practice, and thers whse circumstances change wh need t change back. Patients can pt-ut at any time. Safety Patient safety is f primary imprtance. Warfarin is nt withut risks and it is imprtant that there are several safe guards in place t ensure patient safety. All pharmacists must be accredited t prvide this service. Their practice is clsely regulated by the Standing Order which limits their scpe f practice At least tw pharmacists are trained at each site. The pharmacist requests medical review f any patients utside the test range f 1.5-4. All sites perfrm regular quality cntrl testing. The cmputer system has several features t maintain safety: Patients are asked abut adverse events, new medicatin and hspital visits each time they have a test In additin t the test result being autmatically sent t the Prvider In-bx, if the patient has an INR result utside f the specified safe range (1.5-4), an additinal warning email is sent t the practice with the fllwing: The latest INR result The recmmended dse The date f the next test A graph shwing recent warfarin cntrl A list f previus results The pharmacy cntact details t enable the GP t cntact the pharmacist t discuss dse recmmendatins, and make changes as necessary In the pilt it was identified that sme GPs did nt use e-mail and did nt want the email alerts sent t their persnal e-mail. This prcess has been changed t allw all alerts t be sent t ne address, fr example a shared e-mail fr review by yur nurse r anther cntact persn at the practice. This is an extra safety feature t 1 Keeling D, Baglin T, Tait C, Watsn H, Perry D, Baglin C, et al. Guidelines n ral anticagulatin with warfarin 4 th editin. Br J Haematl. 2011 August; 154(3):311-24.
Reliability ensure yu are fully infrmed f test results that are ut f range. (In additin, as mentined, all test results are sent t the PMS Prvider In Bx). There are many studies cmparing INR results frm the CaguChek XS Plus device with labratry testing, including ne frm this cuntry. These shw an excellent crrelatin between results. (An lder versin f the CaguChek did shw sme discrepancy between results at a high INR, but the mst recent device has been fund t be reliable with all INR results). Quality cntrl Testing is perfrmed under a standard perating prcedure. Pharmacists accredited t prvide this service are required t perfrm quality cntrl testing n a regular basis t ensure the testing device and their prcedures are up t a recgnised standard. They are als required t reprt n adverse events, cmpliance and anticagulant cntrl every three mnths. There is currently n natinal register which dcuments cmplicatins related t warfarin. Hwever, INR Online recrds cmplicatins such as bleeding, and this prvides the pprtunity t mre clsely mnitr natinal trends and prvide audit data abut warfarin use. The place f pint-f-care INR testing in general practice and the cmmunity Yes, there is a place fr INR pint-f-care testing in general practice. Several practices have chsen t purchase the equipment and are ffering this service, thugh they may nt be using the decisin supprt sftware which enables dsing recmmendatins, dcumentatin and analysis f test results, and cnnectivity with ther health systems. The sftware als prvides a dsing calendar able t be given t the patient, and patients find this very useful. Sme members f the public have purchased the equipment t enable self testing at hme. Next steps If yu are apprached by a lcal cmmunity pharmacist specially trained and accredited t prvide this service, r wuld like t ffer this service t yur patients thrugh a lcal participating pharmacy the next steps are: Invlve the practice manager Identify patients wh wuld benefit frm the service The practice nurse might be able t talk t selected patients the next time their test is due and invite them t participate in the service. Cmplete a referral frm fr each patient The pharmacist may als be able t assist by pre-filling ut sme f the infrmatin n the frm. Sign the Standing Orders Ensure yu have a gd prcess in place t allw the pharmacy t cntact yu Wh d I cntact if I have questins? Fr further infrmatin n hw the service wrks cntact lcal pharmacies r general practices invlved in the Cmmunity Pharmacy Warfarin Service. Alternatively, cntact Rbyn.Blue@dhbsharedservices.health.nz - phne 04 803-5822 - wh can answer any questins, and/r put yu in tuch with a lcal pharmacy r a general practice invlved in this service near yu.
Appendix One Results frm the Cmmunity Pharmacy Anticagulatin Management (CPAM) service pilt Studies verseas have shwn that anti-cagulatin management services invlving pharmacists can lead t imprved anticagulatin cntrl, a reduced frequency f warfarin-related hspital admissins, a lwer frequency f drug interactins, and imprved patient cmpliance and satisfactin 2. In 2010/11, a Cmmunity Pharmacy Anticagulatin Management (CPAM) service pilt was undertaken by Health Wrkfrce NZ in cllabratin with the Pharmaceutical Sciety f NZ and the New Zealand Cllege f Pharmacists 3. The results shwed anticagulatin management services by cmmunity pharmacies t be a safe and effective alternative t standard care in general practice. High Cmpliance In the pilt a high level f cmpliance with appintments was achieved, with the majrity f tests (83.1%) perfrmed n r befre the due date. Factrs cntributing t the high level f cmpliance included: increased accessibility f testing cmpared t having the test at a labratry cllectin centre patient preference t having a finger prick cmpared t a bld test immediate infrmatin n the results imprved tracking and fllw-up f patients knwn t be pr attendees Imprved Therapeutic Treatment Range (TTR) As part f the pilt, 6 mnths f prir INR data was btained fr 154 patients frm 6 sites. Fr these patients, the mean time within the therapeutic treatment range (TTR) in the pilt was 77.5%, cmpared t 60.4% befre the pilt. Patient satisfactin In the pilt the large majrity f patients identified the Service t be cnvenient and accessible. They identified it t be preferable t GP care, expressed cnfidence in the pharmacist perfrming the service and fr the service t be cntinued. A small prprtin f patients identified they preferred GP care. 2 Sakaew S, Permsuwan U, Chairyakunapruk N, Nathisuwan S, Siknthasarn A. Effectiveness f pharmacistparticipated warfarin therapy management: a systematic review and meta-analysis. J Thrmb Haemst. 2010 Nv;8(11):2418-27. 3 Cmmunity Pharmacist-led Anticagulatin Management Service Final Reprt. University f Auckland, September 2011. http://www.healthwrkfrce.gvt.nz/abut-us/publicatins-and-reprts/reprts