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Letters to the Editor
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Anticoagulation services
Pharmacists are well placed to meet demand
From Miss F. O. O. Akinwunmi, MRPharmS
I share Duncan McRobbie’s views with regards to the role
of community pharmacists in the provision of anticoagulation services (PJ, 19 March,
p327). There is an increased demand for services because evidence shows
the benefits of warfarin in prevention of stroke1 and because of standard
5 of the National Service Framework for Older People2 (reducing stroke
incidence) coupled with the UK’s ageing population.
With the introduction of near patient testing and computerised decision
support software (CDSS), primary care service models are now a feasible
alternative to the traditional secondary care model.
At the Barts and The London Trust anticoagulation clinic, we have seen
a four-fold increase in patient demand since 1991, which has prompted
an examination of providing community-based anticoagulation services.
The clinic runs one outreach service with a GP practice for a small number
of its patients. We have recently piloted two domiciliary services3 (one
involving a pharmacist using both near patient testing and CDSS) for
mobility-impaired patients who previously had to endure long journeys
to and from the clinic and variable waiting times. Results showed that
during the study domiciliary INR (international normalised ratio) control
was equivalent to that achieved in the clinic4 and that there was a significant
improvement in patient satisfaction.5 A domiciliary service has now been
implemented.
Other studies have shown that warfarin is underused in patients with
atrial fibrillation.6,7 Stroke is the biggest cause of severe disability
and the third most common cause of death in the UK. With this in mind
it is clear that limiting new referrals will lead to marginalisation
of patients and inadequate stroke prevention. This is not the way forward.
Pharmacists are well placed to meet the increased demand and to reduce
the pressure on hospital services. Evidence shows that community pharmacists
can achieve good INR control.8,9 Their understanding of drug interactions
and pharmacokinetics, coupled with their knowledge of local patients,
aids the dosing process. Furthermore, there is a role for pharmacists
in identifying unmet need (eg, screening for patients taking digoxin)
and in supporting self management.
Frances Akinwunmi
Research Pharmacist
School of Pharmacy,
University of London
References
1. Ezekowitz MD, Bridgers SL, James KE, Carliner NH, Colling CL, Gornick
CC et al. Warfarin in the prevention of stroke associated with non-rheumatic
atrial fibrillation. New England Journal of Medicine. 1992;327:1406–12.
2. Department of Health. National Service Framework for Older People.
London: The Department; 2001.
3. Akinwunmi F, Engová D, Duggan C. Development of a role of an
outreach pharmacist in anticoagulation services. Pharmacy World and Science
2004:26(Suppl):A38–A39.
4. Akinwunmi F, Engová D, Duggan C, Madhani M, Bates I, MacCallum
P. Domiciliary anticoagulation service involving a pharmacist: preliminary
trial results. International Journal of Pharmacy Practice 2004;12(Suppl):R84 (PDF 190K)
5. Akinwunmi F, Engová D, Duggan C, Madhani M, Bates I, MacCallum
P. Patient satisfaction with domiciliary anticoagulation service. 11th
Health Services Research and Pharmacy Practice Conference. London: Royal
Pharmaceutical Society; 2005. p28. Available here (accessed 24 March
2005).
6. Sudlow M, Thomson R, Thwaites R, Rodgers H, Kenny RA. Prevalence of
atrial fibrillation and eligibility for anticoagulants in the community.
The Lancet 1998;352:1167–71.
7. McCormick D, Gurwitz JH, Goldberg RJ, Ansell J. Long-term anticoagulation
therapy for atrial fibrillation in elderly patients: efficacy, risk,
and current patterns of use. Journal of Thrombosis and Thrombolysis 1999;7:157–63.
8. Macgregor S, Hamley J, Dunbar JA, Dodd TRP, Cromarty JA. Evaluation
of a primary care anticoagulant clinic managed by a pharmacist. BMJ 1996;312:560–4.
9. Holden K, Holden J. A comparative study of pharmacist and GP management
of anticoagulant therapy following deviation from the target international
normalised ratio. International Journal of Pharmacy Practice 2001;9(Suppl):R24
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