Clinical Outcomes of a Collaborative, Home-Based Postdischarge Warfarin Management Service
Stafford, L and Peterson, GM and Bereznicki, LRE and Jackson, SL and Van Tienen, EC and Angley, MT and Bajorek, BV and McLachlan, AJ and Mullan, JR and Misan, GMH and Gaetani, L, Clinical Outcomes of a Collaborative, Home-Based Postdischarge Warfarin Management Service, The Annals of Pharmacotherapy, 45, (3) pp. 325-334. ISSN 1060-0280 (2011) [Refereed Article]
BACKGROUND: Warfarin remains a high-risk drug for adverse events, especially
following discharge from the hospital. New approaches are needed to minimize
the potential for adverse outcomes during this period.
OBJECTIVE: To evaluate the clinical outcomes of a collaborative, home-based
postdischarge warfarin management service adapted from the Australian Home
Medicines Review (HMR) program.
METHODS: In a prospective, nonrandomized controlled cohort study, patients
discharged from the hospital and newly initiated on or continuing warfarin therapy
received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home
visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days
postdischarge. The PDS involved point-of-care international normalized ratio
(INR) monitoring, warfarin education, and an HMR, in collaboration with the patient’s
general practitioner and community pharmacist. The primary outcome measure
was the combined incidence of major and minor hemorrhagic events in the 90
days postdischarge. Secondary outcome measures included the incidences of
thrombotic events, combined hemorrhagic and thombotic events, unplanned and
warfarin-related hospital readmissions, death, INR control, and persistence with
therapy at 8 and 90 days postdischarge.
RESULTS: The PDS (n = 129) was associated with statistically significantly
decreased rates of combined major and minor hemorrhagic events to day 90
(5.3% vs 14.7%; p = 0.03) and day 8 (0.9% vs 7.2%; p = 0.01) compared with
UC (n = 139). The rate of combined hemorrhagic and thrombotic events to day
90 also decreased (6.4% vs 19.0%; p = 0.008) and persistence with warfarin
therapy improved (95.4% vs 83.6%; p = 0.004). No significant differences in
readmission and death rates or INR control were demonstrated.
CONCLUSIONS: This study demonstrated the ability of appropriately trained
accredited pharmacists working within the Australian HMR framework to reduce
adverse events and improve persistence in patients taking warfarin following
hospital discharge. Widespread implementation of such a service has the
potential to enhance medication safety along the continuum of care.
adverse drug events, community pharmacy services, international