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Telephone Versus In-Office Anticoagulation Management
James B. Groce, Pharm.D., CACP
January, 2007
Reference: Wittkowsky AK, Nutescu EA, Blackburn J, Mullins J, Hardman J, Mitchell J, Vats V. Outcomes of Oral Anticoagulant Therapy Managed by Telephone vs. In-Office Visits in an Anticoagulation Clinic Setting. CHEST. 2006;130:1385-1389.
Oral anticoagulation management of warfarin (Coumadin®) through a specially focused-systematic means of oversight is often rendered from anticoagulation clinics whose focus may be solely upon warfarin. Busy office-based practices of physicians, whether primary care focused or specialty-based focused, are responsible for a myriad of disease states and therapeutic drug monitoring.
Pharmacist managed anticoagulation care from the clinic setting has been reported to improve patient outcomes of both efficacy and safety with warfarin.1-4 Because of burgeoning patient populations taking wafarin as well as market forces upon such pharmacist managed clinics, (e.g. reduced or eliminated funding for such clinics) many pharmacists and healthcare systems have developed telephone-based management of anticoagulation.5-7 Telephone-based anticoagulation management compared to office-based - "usual medical care" anticoagulation management have offered conflicting results.8,9
Wittkowsky, Nutescu, Blackburn et al compared the outcomes of patients managed by telephone versus by-office appointments within two anticoagulation clinic settings. The intervention group was managed by telephonic management, whereas the control group included patients whose anticoagulation management occurred during face-to-face office-based visits.10
Patient monitoring outcomes, clinical end points and use of health-care resources were compared for 234 patients, 117 in each group. There were found to be no statistical differences between patients managed by telephone versus by-office appointments for number of INRs, frequency of encounters with the patients, rates of major hemorrhage and recurrence of thromboembolism. Similarly, there were no statistical differences in rates of warfarin-related emergency department visits or hospital admissions between the two groups.
This important study answered a question that many anticoagulation care providers ask for patients within their same clinic setting - "are there differences for patients that we may see face-to-face versus those we manage telephonically within our same clinic?"
Many variables impact our decision to make an individual patient a "face-to-face" or a telephonically managed patient. Mitigating against the necessity of face-to-face management is the issue of patients who fail to keep regularly scheduled office appointments. Traditional barriers impacting the patient's ability to keep his/her appointment (e.g. personal preference, geographic inaccessibility, lack of transportation, immobility, etc.) make difficult our ability to offer efficacy and safety for anticoagulant drugs for patients who refuse or cannot attend our clinics for face-to-face appointments. This study suggests that the effectiveness of telephone-based management for patients may be an alternative for those who previously we may have discharged from our clinics for successive "missed-appointments."
Imperative to the successes of either management strategy is a systematic means of oversight that includes appropriate, standardized data collection forms for each patient population and patient education focusing upon the requirement of patients to self-report complications - between both telephonic management calls and face-to-face office-based encounters.
References:
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Garabedian-Ruffalo SM, Gray DR, Sax MJ, et al. Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic. Am J Hosp Pharm. 1985;42:304-308.
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Wilt VM, Gums JG, Ahmed OI, et al. Outcome analysis of a pharmacist-managed anticoagulation service. Pharmacotherapy. 1995;15:732-739.
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Gray DR, Garabedian-Ruffalo SM, Chretien SD. Cost-justification of a clinical pharmacist-managed anticoagulation clinic. Drug Intell Clin Pharm. 1985;19:575-580.
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Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care. Arch Intern Med. 1998;158:1641-1647.
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Moherman LJ, Kolar MM. Complication rates for a telephone-based anticoagulation service. Am J Health Syst Pharm. 1999;56:1540-1542.
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Foss MT, Schoch PH, Sintek CD. Efficient operation of a high-volume anticoagulation clinic. Am J Health Pharm. 56:443-449.
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Waterman AD, Banet G, Milligan PE, et al. Patient and physician satisfaction with a telephone-based anticoagulation clinic. J Gen Intern Med 2001;19:460-463.
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Goldberg Y, Meytes D, Shabtai E, et al. Monitoring oral anticoagulant therapy by telephone communication. Blood Coagul Fibrinolysis. 2005;16:227-230.
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Witt DM, Sadler MA, Shanahan RL, et al. Effect of centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127:1515-1527.
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Wittkowsky AK, Nutescu EA, Blackburn J, Mullins J, Hardman J, Mitchell J, Vats V. Outcomes of oral anticoagulant therapy managed by telephone vs. in-office visits in an anticoagulation clinic setting. Chest. 2006;130:1385-1389.
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