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11/15/2000

Telephone Aids in Anticoagulation Management

Tzipora R. Lieder,
George P. Provost Editorial Intern

A pharmacist's close contact with a patient during months of fine-tuning therapy invariably leads to some familiarity between the two. But a member of Dan Witt's anticoagulation team passing a patient on the street would receive no acknowledgment. The reason is simple: Never having met face-to-face, the pharmacist and patient would not recognize one another.

The 12 pharmacists and 2 pharmacy technicians who staff the clinical pharmacy anticoagulation service at Kaiser Permanente Colorado Region, where Witt is chief of clinical pharmacy anticoagulation and cardiac risk services, manage the anticoagulation therapy of over 4800 patients entirely by telephone. Since 1997, the centralized service has optimized the use of human and other resources to enable a small team to cover patients throughout the Denver–Boulder metropolitan area.

Making the connection. When patients at any of the region's 16 Kaiser Permanente medical offices are diagnosed with conditions requiring anticoagulation, the facility's clinical pharmacists usually counsel the patients and begin the appropriate therapy, said Kent Nelson, clinical pharmacy services administrator at Kaiser Permanente Colorado. Then, responsibility for this aspect of patient care shifts to the pharmacists at the centralized service. At times, physicians contact the service immediately, bypassing the facility's clinical pharmacists. Diagnoses of patients enrolled in the service, said Nelson, include atrial fibrillation, deep vein thrombosis (DVT), high-risk pregnancy, clotting disorders, and joint replacement.

All of the pharmacists have individual rosters of patients, to which new patients are added on a rotating basis. To ensure continuity of care, patients remain on a specific pharmacist's roster for the duration of their enrollment with the service. This can range from three months—for a single episode of DVT—to an indefinite period—for an indication such as atrial fibrillation, which requires lifelong anticoagulation.

Patient care by the anticoagulation service starts with several lengthy introductory phone calls during which the pharmacists gather patient information and provide education on the risks and benefits of anticoagulation therapy. The patients return to their usual Kaiser facilities for regular blood tests; the results are processed centrally and entered in patients' electronic medical records. The anticoagulation pharmacists evaluate the data, ask the patients about symptoms of bleeding, and adjust therapy in accordance with a protocol authorized by the Kaiser physician group. During the initial management phase, patients may be monitored as frequently as every few days, but once therapy has stabilized, monitoring decreases to every two to four weeks.

The telephone lines work both ways. Patients are welcome to call the service at any time to discuss concerns or symptoms they are having; a pharmacist is available 24 hours a day, seven days a week to respond to these calls. Nelson considers the pharmacists' accessibility an important component of the service. Anticoagulation therapy is potentially dangerous, so contact with patients is crucial. This contact, Nelson said, is bolstered by patients' knowledge that "they have someone who is very quick to help them to manage that therapy appropriately and to help them to understand the risks."

Charting a course. The anticoagulation service's database provides a structured format for documenting laboratory values such as International Normalized Ratio (INR), adverse effects, drug interactions, and other pertinent information. Pharmacists supplement these data with free-text progress notes and document every conversation with patients as well. The database's dose-calculation algorithm can generate estimates of dosage adjustments, but this technology does not substitute for clinical judgment. "Computers do make mistakes," Nelson stressed, and pharmacists must be on the lookout for situations in which "there's a very good explanation for a patient's change in INR," when the dose should not be changed despite the computer's suggestions.

Information collected in the database is useful in tracking not only the progress of individual patients but also trends in the population as a whole. For example, the pharmacists can evaluate patterns in the occurrence of minor and major complications of therapy and, when necessary, delve further into cases in which patients have had adverse effects. Quality assurance data generated by the database were used for a pharmacoeconomic analysis published by the service in the October 23, 2000, issue of Archives of Internal Medicine (PDF). For the analysis, pharmacists evaluated the effectiveness and economic impact of their outpatient treatment of DVT, for which they use low-molecular-weight heparin and gradually change to warfarin.

A current disadvantage of the database is that it does not link to Kaiser's electronic medical records system. This results in some duplication of efforts: Pharmacists must manually input lab results from the medical record into the database and document all dosage adjustments in the medical record.

The people behind the voices. With all 14 staff members working in cubicles at one of Kaiser's medical facilities, Nelson said, there is the advantage of a "built-in support group." As questions arise, pharmacists "don't have to guess" but have colleagues nearby with whom to confer. New pharmacists who join the service work with the veterans while gaining the confidence to go solo.

The roles of the various employees differ somewhat based on background and level of expertise. Among the pharmacists, some have had residency training in toxicology, family medicine, or cardiology, while others have migrated from more dispensing-oriented positions. Patient management activities are shared by all the pharmacists, and the clinical pharmacy specialists with residency experience have additional quality assurance responsibilities. Pharmacy technicians answer telephones, gather demographic data on new patients, generate reports on patients overdue for blood tests, and contact these patients with reminders.

A piece of the Kaiser machine. Kaiser Permanente's closed medical system helps to ensure the integration of patients' care. When a patient fills a prescription for a potentially interacting drug at one of Kaiser's pharmacies, the dispensing pharmacist notifies the patient's anticoagulation pharmacist, who can then take action as needed. One of the pharmacists on the service regularly attends clinical rounds and consults with physicians at the Denver hospital Kaiser contracts with, so the service can keep tabs on its patients when they are hospitalized.

While the pharmacists handle most of the patient anticoagulation issues, said Nelson, they confer with physicians or refer patients for evaluation when necessary. The physicians are receptive to the pharmacists' work, he reported, welcoming the opportunity to focus on other aspects of patients' care while feeling confident that management of their anticoagulation therapy is in capable hands. Occasionally, new Kaiser physicians may be wary, said Nelson, but "the testimonials of their colleagues do much more than we could ever do" to promote the merits of the service. He estimated that fewer than 10 Kaiser anticoagulation patients in the region are not enrolled in the service.

While the use of telepharmacy poses challenges at times, members of the service can find creative solutions to most problems. Visiting nurses can help homebound patients, and translation services offer a way around language barriers. "We've never had a situation [in which] we couldn't mobilize resources to take care of a patient," said Nelson.

Unforeseen growth. When the service was started, a patient load of 3700 was projected. That number has grown by nearly a third, and employees have been added to handle the increased workload. It's not only the number of patients that determines the staffing needs of the service, said Nelson, but also the complexity of the patient population. The expanding indications for anticoagulation therapy have altered some of the requirements for patient care. For example, Nelson said, patients with artificial joints require more intensive monitoring than atrial fibrillation patients who have been stabilized on warfarin for years. But Kaiser's main impetus to expand the service, Nelson said, is the desire to ensure that it continues providing the value it has shown over the years, not only in reducing the number of complications, but also in saving costs and improving quality of care and patient satisfaction.