Dr : Osama Badry Cardiology /Anticogaulation Coordinator Incharge of Anticoagulation Service AWH-HMC/Qatar

“ The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine. (2001). National Academy Press “ The provision of the necessary health care service to the appropriate person at appropriate time, and using the best means with the objectives of getting the best results for each individual patient, and the community at large.” Qatar Supreme Council of Health

Effective Patient- centered TimelyEfficient Quality of Care Scientific Knowledge Waiting Time Patients’ Needs Wasteful Practices

Warfarin : Effective rat poison

Warfarin Therapy Warfarin –Most widely used vitamin K antagonists(VKAs) worldwide in the prevention of treatment of blood clots. it’s used complicated by various factors Ansell J.et.al 2004,Bungard TJ,et.al.2009,Hamby L,et.al 2000  Utilizing the correct intensity and maintaining the patient in the therapeutic-determinant of its therapeutic effectiveness and safety Ansell J.et.al 2004,Yi W.et.al.2008,kamali F.et.al,2010  3 primary models available for managing oral anticoagulant care are usual medical care, anticoagulation clinic, patient self management Wilson SJ.et.al 2003

Question Is the pharmacist managed anticoagulation more effective than usual care?

Anticoagulation Clinic (AC) Anticoagulation management services(AMSs) (i.e.; anticoagulation clinics) is accepted as gold standard and one of the approaches to improve anti Coagulant care Ansell J et al Pharmacist Managed AMS in comparison to other clinics (physician / Nurses) : Achieve superior anticoagulation control Favorable impact on hospitalization Ruud KM. et al. 2010

Pharmacist Managed AC  Pharmacist-staffed Acs provided patient education, a more consistent monitoring and early recognition of risk factors. Chamberlain MA. et.al.2001  Pharmacist –managed AC service demonstrated decreased advers events(39-47 % bleeding) and reduced hospital costs (USD per patient). Saokaew S.2010, You JHS CA.et al.2008

Quality Team

No systematic approach for tracking and scheduling INRs. No specific dosing nomogram or protocol are utilized ; only individual physician knowledge and experience with management of warfarin is utilized. Patients who are not getting their lab work done routinely may not discovered until a doctor’s appointment or a prescription renewal. Long waiting time resulted in patient’ frustration and low satisfaction. No structured education or counseling for patients and/or their families. Unavailability of the treating physicians. No active participation for other health care providers e.g. Pharmacists, Patient educators and dieticians. Follow-up appointment depends on physician’s scheduling. No structured evaluation of service e.g non adherence to warfarin therapy.

Conclusion: The pharmacist-managed anticoagulation program within a family practice clinic compared to usual care by the physicians achieved significantly better INR control as measured by the percentage of time patients’ INR values were kept in both the therapeutic and expanded range. Based on the results of this study, a collaborative family practice clinic using pharmacists and physicians may be an effective model for anticoagulation management with these results verified in future prospective randomized studies.

Impact of PDAS on Quality and Safety of HIT Management

Outcome with pharmacist – and physician- managed warfarin mediated anticoagulation

Efficacy with pharmacist –managed in-hospital anticoagulation

Garwood et al 2008

Process of implementation Pharmacy Director Idea Cardiology Champion Multdisciplinary Subcommittee Pharmacy & Therapeutic Committee Senior Executive Clinical complexity Provision of resources and support

Challenges ResourcesPhysician resistancePatient satisfaction Referral and first appointment

Anticoagulation clinic statistics Total Number of Patients May September 2014

IndicationNo AF59 MVR9 AVR8 DVR5 L-V thrombus7 Pulmonary hypertension2 DVT38 Pulmonary Embolism28 Portal vein thrombosis2 Stroke3 APS3 Sever AS,MR1 Right portal vein thrombosis1 Post MI, LV aneurysm1 IVC1 Low EF1 Cerebral vein thrombosis2 Total171

MonthNo May / June/ July/ August / September/ October/ November/ December/ JANUARY / February / March/ April/ May/ June/ July/ August/ September/ TOTAL1410

Research done in collaboration with Qatar university, ‘’ Satisfaction and quality of life of patients attending an ambulatory pharmacist-managed anticoagulation clinic in Qatar’’, see the supporting evidence. The quantitative improvement was done by calculation of TTR (time in therapeutic range) a metric of how well patients are managed on warfarin therapy by using software program, the result is 77.8warfarin Another two ongoing researches were accepted by research center 1-‘’evaluation of clinical and economical outcomes at pharmacist versus physicians –based anticoagulation outpatient clinic and its impact on the cardiovascular disease management in Qatar”” 2-‘’ The Effect of Genetic Variants on Warfarin Dosing and Its Impact on Cardiovascular Outcomes in Qatar’’

 Strong and effective leadership  Multidisciplinary Team  Quality Improvement  First clinic run by a clinical pharmacist in HMC/ QATAR

Progress does not involve replacing one theory that is wrong with one that is right, rather it involves replacing one theory that is wrong with one that is more subtly wrong. Hawkins Law