Clinical impact of a pharmacist-led inpatient anticoagulation service: a review of the literature

Figures & data

Table 1 Summary of included trials

Author (year)	Study design	Patient population	Medications	Sample size	Statistically significant results for pharmacist group
PMAP
Dawson et al^Citation6 (2011)	Prospective, nonrandomized trial	Patients who received at least one dose of warfarin for any indication	Warfarin	p =217 (protocol); c =293 (physician dosing)	Fewer INR results >5.0
To and Jackevicius^Citation26 (2011)	Prospective/retrospective cohort	Patients with suspected or documented HIT who received a continuous infusion of a DTI for at least 24 hours	Lepirudin, argatroban	p =98 (protocol); c =95 (primary team; preprotocol)	Shorter time to achieve therapeutic aPTT, greater percentage of time in target aPTT range, less TIMI major bleeding
Brice^Citation8 (2001)	Prospective cohort	All warfarin patients on general medicine, elderly medicine, step-down CCU	Warfarin	p =67 (pharmacist dosing); c =65 (physician dosing)	Less pseudoevents (INR ≥5 or ≤1.5)
Damaske and Baird^Citation13 (2005)	Prospective cohort	DVT/VTE, PE, AF, CVA	Warfarin	p =29 (protocol); c =22 (physician dosing)	None
Mamdani et al^Citation18 (1999)	Prospective cohort	Admitted for DVT/PE and received IV heparin	Heparin, warfarin	p =50 (heparin weight-based protocol; warfarin dosing nomogram); c =50 (physician dosing)	Less subtherapeutic aPTTs, greater percentage of therapeutic aPTT values, shorter time between blood draws and response to nontherapeutic aPTT. Earlier warfarin start and shorter LOS
Chenella et al^Citation17 (1983)	Prospective RCT	Patients referred to the anticoagulant service	Heparin, warfarin	p =42 (protocol); c =39 (physician; protocol)	None
Cooper et al^Citation25 (2012)	Retrospective cohort	Adult patients with suspected HIT treated with a DTI for >24 hours	Argatroban, bivalirudin	p =25 (protocol); c =25 (usual care, preprotocol)	Achieved therapeutic aPTT sooner and percent total time at therapeutic aPTT was greater
Airee et al^Citation11 (2009)	Retrospective cohort	MI, VTE, AF, or CVA new to warfarin with goal INR range 2–3	Warfarin	p =50 (protocol); c =50 (physician dosing)	Longer time to therapeutic INR but less drug interactions
Chilipko and Norwood^Citation10 (2014)	Retrospective cohort	Receiving warfarin for 3 days consecutively (excluding orthopedic surgery)	Warfarin	p =179 (pharmacist dosing) c =179 (physician dosing)	Time within therapeutic INR greater but longer LOS
Saya et al^Citation21 (1985)	Retrospective cohort	All medical–surgical patients receiving heparin by continuous IV infusions	Heparin	p =26 (weight-based protocol); c =62 (physician empiric dosing)	None
Tschol et al^Citation7 (2003)	Prospective/ retrospective cohort	Postcardiac valve surgery	Warfarin	p =97 (nomogram); c =130 (physician dosing)	Fewer days with INR >5.0
Rivey et al^Citation16 (1995)	Prospective/retrospective cohort	Orthopedic surgery	Warfarin	p =151 (protocol); c =41 (physician dosing)	None
Boddy^Citation9 (2001)	Prospective cohort	Acute medical wards (DVT, PE, AF, etc)	Warfarin	p =74 (protocol); c =68 (physician dosing) c =64 (physicians dosing with protocol)	Greater proportion of patients within target INR
Schillig et al^Citation14 (2011)	Cluster RCT	All patients receiving warfarin in two medical and two cardiology units	Warfarin	p =250 (pharmacist dosing); c =250 (physician dosing)	Greater compliance with transition of care metric
Lobo et al^Citation27 (2010)	Prospective/ retrospective cohort	Patients with confirmed HIT	Argatroban, lepirudin	p =17 (revised protocol); c =18 (physician; protocol)	Less dosing errors and reexposure to heparin
Hosmane et al^Citation15 (2010)	Prospective cohort	Postcardiac surgery	Warfarin	p =46 (pharmacist dosing); c =50 (physician dosing)	None
Burns^Citation12 (2004)	Prospective cohort	All warfarin medical patients in wards for the elderly	Warfarin	p =33 (protocol); c =33 (protocol)	None
Bond and Raehl^Citation19 (2004)	Retrospective hospital database review	Medicare patients receiving anticoagulation in US hospitals	Heparin (h); warfarin (w)	(h) p =148,597; (h) c =568,799; (w) p =84,219; (w) c =633,177	Lower mortality, reduced length of stay, and fewer bleeding complications
Pawloski and Kersh^Citation20 (1992)	Prospective cohort	Patients receiving full-dose continuous IV heparin therapy	Heparin	Phase I: p =29 (weight-based protocol); c =14 (physician, ± weight-based protocol) Phase II: p =31 (weight-based protocol); c =14 (physician, ± weight-based protocol)	Time to therapeutic aPTT was shorter in pharmacist group
Pharmacist recommendation
Ellis et al^Citation28 (1992)	Prospective/retrospective cohort	Inpatients receiving warfarin	Warfarin	p =52 (pharmacist recommendation); c =97 (physician dosing)	Decrease in the frequency of PT and PTT testing, greater PT stability, and increased referrals to the outpatient clinic
Cronin et al^Citation34 (2009)	Prospective/retrospective cohort	Orthopedic surgery	Any	p =953 (protocol); c =1,003 (physician dosing)	None
Dager and Gulseth^Citation31 (2000)	Prospective/retrospective cohort	Inpatients with new warfarin prescription	Warfarin	p =60 (pharmacist recommendation); c =60 (physician dosing)	Decrease in the number of days on warfarin, less days with INR >3.5 or >6, lower percentage of patients with INR >3.5 or >6, and fewer patients receiving medications with major interactions with warfarin
Bauer et al^Citation33 (2008)	Prospective cohort	All inpatients, excluding maternity, nursery, pediatric, and psychiatry	Any	p =3,876 patient days (protocol); c =4,151 patient days (physician dosing)	Increased percentage of patients with VTE prophylaxis and decreased percentage of discharges with DVT
Biscup-Horn et al^Citation32 (2008)	Retrospective cohort	Cardiac surgery patients (CABG and valve surgery) receiving warfarin	Warfarin	p =152 (protocol); c =674 (physician dosing)	Decreased percentage of patients with INR >5 and decreased postsurgical LOS
Wong et al^Citation30 (2010)	Prospective cohort	General medicine and surgery: new start on warfarin for DVT, PE, and AF	Warfarin	p =144 (protocol); c =26 (physician dosing)	Increase in percentage of INR values in therapeutic range within 5 days, decreased percentage of INR>4 and subtherapeutic INR on discharge, decreased time to therapeutic INR and time to discharge
Thompson et al^Citation29 (2012)	Retrospective cohort	Inpatients receiving warfarin	Warfarin	p =100 (pharmacist recommendation); c =100 (physician dosing)	Increased time in INR goal range and decreased time to goal INR

Abbreviations: AF, atrial fibrillation; aPTT, activated partial thromboplastin time; c, control; CABG, coronary artery bypass graft; CCU, coronary care unit; CVA, cerebrovascular accident; DTI, direct thrombin inhibitor; DVT, deep vein thrombosis; h, heparin; HIT, heparin-induced thrombocytopenia; INR, international normalized ratio; IV, intravenous; LOS, length of stay; MI, myocardial infarction; p, pharmacist; PE, pulmonary embolism; PMAP, pharmacist-managed anticoagulation program; PT, prothrombin time; PTT, partial thromboplastin time; RCT, randomized controlled trial; TIMI, Thrombolysis in Myocardial Infarction criteria; VTE, venous thromboembolism; w, warfarin.

Table 2 Intravenous heparin therapy: time (hours) to achieve therapeutic aPTT

Author (year)	Pharmacist care (PMAP)	Usual care	P-value
Mamdani et al^Citation18 (1999)	23.6	25.3	0.14
Saya et al^Citation21 (1985)	22.9	35	Statistical analysis not performed
Pawloski and Kersh^Citation20 (1992)	9.32	31.64	<0.001

Abbreviations: aPTT, activated partial thromboplastin time; PMAP, pharmacist-managed anticoagulation program.

Table 3 DTI therapy: time (hours) to therapeutic aPTT

Author (year)	Pharmacist care (PMAP)	Usual care	P-value
Cooper et al^Citation25 (2012)	3.4	7.7	0.009
To and Jackevicius^Citation26 (2011)	6.4	18.9	<0.001

Abbreviations: aPTT, activated partial thromboplastin time; DTI, direct thrombin inhibitor; PMAP, pharmacist-managed anticoagulation program.

Table 4 DTItherapy: percentage of time in therapeutic aPTT

Author (year)	Pharmacist care (PMAP)	Usual care	P-value
Cooper et al^Citation25 (2012)	93	81	0.001
To and Jackevicius^Citation26 (2011)	84.7	64.4	<0.001

Abbreviations: aPTT, activated partial thromboplastin time; DTI, direct thrombin inhibitor; PMAP, pharmacist-managed anticoagulation program.

Table 5 Warfarin therapy: documented or major bleeding

Author (year)	Pharmacist care (recommendation)	Usual care	P-value
Dager and Gulseth^Citation31 (2000)	10%	2%	0.11
Ellis et al^Citation28 (1992)	2%	0%	0.42
Biscup-Horn et al^Citation32 (2008)	1.3%	3.1%	0.22

Table 6 Warfarin therapy: recurrence of thrombosis

Author (year)	Pharmacist care (recommendation)	Usual care	P-value
Ellis et al^Citation28 (1992)	3.1%	3.8%	0.57
Biscup-Horn et al^Citation32 (2008)	3.9%	3.4%	0.75

DawsonNLPorterIE2ndKlipaDInpatient warfarin management: pharmacist management using a detailed dosing protocolJ Thromb Thrombolysis201233217818422081292

 PubMed Web of Science ®Google Scholar

ToEJackeviciusCQuality improvement initiative for pharmacist-assisted warfarin dosing: implementation and evaluation of a new protocolCan J Hosp Pharm2002552105113

 Google Scholar

BriceSDA comparative evaluation of doctor and pharmacist managed inpatient anticoagulationPharm Pract2001114134137

 Google Scholar

DamaskeDLBairdRWDevelopment and implementation of a pharmacist-managed inpatient warfarin protocolProc (Bayl Univ Med Cent)200518439740016252031

 PubMedGoogle Scholar

MamdaniMMRacineEMcCreadieSClinical and economic effectiveness of an inpatient anticoagulation servicePharmacotherapy19991991064107410610013

 PubMed Web of Science ®Google Scholar

ChenellaFCKlotzTAGillMAComparison of physician and pharmacist management of anticoagulant therapy of inpatientsAm J Hosp Pharm19834010164216456638026

 PubMedGoogle Scholar

CooperTWhiteCLTaberDUberWEKokkoHMazurJSafety and effectiveness outcomes of an inpatient collaborative drug therapy management service for direct thrombin inhibitorsAm J Health Syst Pharm201269221993199823135566

 PubMed Web of Science ®Google Scholar

AireeAGuirguisABMohammadRAClinical outcomes and pharmacists’ acceptance of a community hospital’s anticoagulation management service utilizing decentralized clinical staff pharmacistsAnn Pharmacother200943462162819318602

 PubMed Web of Science ®Google Scholar

ChilipkoAANorwoodDKEvaluating warfarin management by pharmacists in a community teaching hospitalConsult Pharm20142929510324513419

 PubMedGoogle Scholar

SayaFGColemanLTMartinoffJTPharmacist-directed heparin therapy using a standard dosing and monitoring protocolAm J Hosp Pharm1985429196519694050813

 PubMedGoogle Scholar

TscholNLaiDKTilleyJAWongHBrownGRComparison of physician- and pharmacist-managed warfarin sodium treatment in open heart surgery patientsCan J Cardiol200319121413141714631476

 PubMed Web of Science ®Google Scholar

RiveyMPWoodRDAllingtonDRStrattonTPEricksonCCStensonTAPharmacy-managed protocol for warfarin use in orthopedic surgery patientsAm J Health Syst Pharm19955212131013167656118

 PubMed Web of Science ®Google Scholar

BoddyCPharmacist involvement with warfarin dosing for inpatientsPharm World Sci2001231313511344589

 PubMedGoogle Scholar

SchilligJKaatzSHudsonMKrolGDSzandzikEGKalusJSClinical and safety impact of an inpatient pharmacist-directed anticoagulation serviceJ Hosp Med20116632232821834113

 PubMed Web of Science ®Google Scholar

LoboBFinchCHoward-ThompsonAGillionAPharmacist-managed direct thrombin inhibitor protocol improves care of patients with heparin-induced thrombocytopeniaHosp Pharm2010459705

 Google Scholar

HosmaneSRTuckerJOsmanDWilliamsSWaterworthPInpatient oral anticoagulation management by clinical pharmacists: safety and cost effectivenessJ Clin Med Res201022909221811526

 PubMedGoogle Scholar

BurnsNEvaluation of warfarin dosing by pharmacists for elderly medical in-patientsPharm World Sci200426423223715446781

 PubMedGoogle Scholar

BondCARaehlCLPharmacist-provided anticoagulation management in United States hospitals: Death rates, length of stay, medicare charges, bleeding complications, and transfusionsPharmacotherapy200424895396315338843

 PubMed Web of Science ®Google Scholar

PawloskiSJKershPLTherapeutic heparin monitoring service in a small community hospitalHosp Pharm199227870372310119735

 PubMedGoogle Scholar

EllisRFStephensMASharpGBEvaluation of a pharmacy-managed warfarin-monitoring service to coordinate inpatient and outpatient therapyAm J Hosp Pharm19924923873941554003

 PubMedGoogle Scholar

CroninMHillTReichDPinardBKraussESImplementation of a multidisciplinary, pharmacy-led, thromboprophylaxis program in total-joint arthroplasty patientsAm J Health Syst Pharm200966217117519139483

 PubMed Web of Science ®Google Scholar

DagerWEGulsethMPImplementing anticoagulation management by pharmacists in the inpatient settingAm J Health Syst Pharm200764101071107917494907

 PubMed Web of Science ®Google Scholar

BauerJBChunDSKarpinskiTAPharmacist-led program to improve venous thromboembolism prophylaxis in a community hospitalAm J Health Syst Pharm200865171643164718714111

 PubMed Web of Science ®Google Scholar

Biscup-HornPJStreiffMBUlbrichTRNesbitTWShermockKMImpact of an inpatient anticoagulation management service on clinical outcomesAnn Pharmacother200842677778218460587

 PubMed Web of Science ®Google Scholar

WongYMQuekYNTayJCChadachanVLeeHKEfficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titrationJ Clin Pharm Ther201136558559121070296

 PubMed Web of Science ®Google Scholar

ThompsonSSHannanCHoldenLFlickingerDImpact of an inpatient anticoagulation monitoring programUS Pharm2012372HS16HS22

 Google Scholar