Department of Pharmacy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
Department of Statistics and Operations Research, Faculty of Science, University of Malta, Msida, Malta.
Int J Clin Pharm. 2019 Jun;41(3):741-750. doi: 10.1007/s11096-019-00824-4. Epub 2019 Apr 22.
Background Medicine use review by pharmacists has the potential to improve anticoagulation therapy management in patients on warfarin. Objective To develop, implement and evaluate a pharmacist-led medication use review service for patients on warfarin. Setting Six community pharmacies in Malta. Method Patients (N = 100) aged 18 or older and on warfarin were recruited through pre-selected community-pharmacies. These patients were then invited to attend two sessions: a review session (t) and a follow-up session after 2 months (t). During the medication use review session, medication reconciliation was performed (a) to detect drug-related problems using the DOCUMENT classification system, (b) to develop an individualised care plan for each patient and (c) to recommend an action for each identified problem for physician, pharmacist or patient consideration. At t, the degree of acceptance of the recommendations was determined by assessing the number of drug-related problems for which action was taken to address the problem. International normalisation ration (INR) control was evaluated by calculating the percentage Time in Therapeutic Range (TTR) at t and t using the Rosendaal linear interpolation method. Main outcome measures Frequency and type of drug-related problems detected; percentage of accepted recommendations; and INR control. Results A total of 481 drug-related problems were identified; 40% (n = 190) were related to warfarin treatment. Need for monitoring (30%; n = 145), lack of compliance (20%; n = 97) and need for patient education (19%; n = 90) were the top three problems identified. There was a significant correlation between frequency of the problems and number of chronic medications (Spearman Correlation 0.583, p < 0.001), number of comorbidities (Spearman Correlation 0.327, p = 0.001) and older age (Spearman Correlation 0.285, p = 0.04). A total of 475 recommendations were followed-up; 49% (n = 234) were referred for consideration by the physician. The percentage of recommendations accepted (84%; n = 397) was significantly higher than the percentage of recommendations not accepted (16%; n = 78) (p < 0.001). The time in therapeutic range improved significantly from 68.7% at t to 79.8% at t (p = 0.01). Conclusions The high percentage of accepted recommendations and the improvement in INR control indicate that a pharmacist-led medication use review service in community pharmacy contributes to improving anticoagulation therapy management in patients on warfarin.
背景 药剂师进行的药物使用审查有可能改善华法林患者的抗凝治疗管理。目的 开发、实施和评估药剂师主导的华法林患者用药审查服务。地点 马耳他的六家社区药房。方法 通过预选的社区药房招募年龄在 18 岁或以上且正在服用华法林的患者（N=100）。然后邀请这些患者参加两个会议：审查会议（t）和两个月后的随访会议（t）。在药物使用审查会议期间，进行药物重整（a）使用 DOCUMENT 分类系统检测药物相关问题，（b）为每位患者制定个性化护理计划，以及（c）为医生、药剂师或患者考虑，针对每个识别的问题提出建议。在 t 时，通过评估采取行动解决问题的药物相关问题的数量，确定建议的接受程度。通过使用 Rosendaal 线性内插法计算 t 和 t 时国际标准化比值（INR）的治疗范围内时间百分比（TTR）来评估 INR 控制。主要观察指标 检测到的药物相关问题的频率和类型；接受建议的百分比；以及 INR 控制。结果 共发现 481 例药物相关问题；40%（n=190）与华法林治疗有关。需要监测（30%；n=145）、缺乏依从性（20%；n=97）和需要患者教育（19%；n=90）是发现的前三个问题。问题的频率与慢性药物的数量（Spearman 相关系数 0.583，p<0.001）、合并症的数量（Spearman 相关系数 0.327，p=0.001）和年龄较大（Spearman 相关系数 0.285，p=0.04）之间存在显著相关性。共跟进了 475 条建议；49%（n=234）被推荐供医生考虑。接受建议的百分比（84%；n=397）明显高于不接受建议的百分比（16%；n=78）（p<0.001）。TTR 时间从 t 时的 68.7%显著提高到 t 时的 79.8%（p=0.01）。结论 高比例的建议被接受以及 INR 控制的改善表明，社区药房中由药剂师主导的药物使用审查服务有助于改善华法林患者的抗凝治疗管理。
