Anticoagulation Monitoring: The Next Community Pharmacy Value Proposition

An independent pharmacy in Virginia provides patient care services through an anticoagulation clinic.

Located in historic Bon Air, Virginia, Buford Road Pharmacy has been a locally owned and operated pharmacy for over 50 years. In addition to serving the prescription needs of thousands of members of the community, the pharmacy offers a number of patient care services, including routine and travel immunizations, point-of-care testing, and anticoagulation monitoring. By utilizing pharmacy residents and student pharmacists, these services can be offered at a competitive cost and at a time and location that is convenient to the consumer. This independent pharmacy has proved to be a vital part of the community with the expansion of patient care services throughout the years.

By placing these patient care services in the community pharmacy setting, not only are they easily accessible to the patient-consumer, they are also convenient and cost-effective. Services are offered on a walk-in or appointment basis, which allows the patient to be seen at a time that is most convenient for them, whether it be before work, during their lunch break, or on the weekend. In addition, the community pharmacy is able to offer these services at a reduced cost to the patient through use of strategies such as limited administrative costs, use of student pharmacists and community pharmacy residents, and competitive pricing on products and services that are not covered by insurance.

The Anticoagulation Clinic

The anticoagulation clinic at Buford Road Pharmacy was established in 2007 and is operated by the staff pharmacists, a community pharmacy practice resident, and frequently by supervised fourth-year doctor of pharmacy students. All of the pharmacists employed at Buford Road are trained to perform anticoagulation management services, which allow the patients to visit the pharmacy at any time during the expansive business hours for anticoagulation management. For many of the patients who are already visiting the pharmacy to pick up a prescription or OTC item, the location of the anticoagulation clinic is convenient and highly accessible. The pharmacy has 2 individual counseling rooms where patients can meet privately with a pharmacist for testing and counseling during their visit.

When the collaborative practice agreement was written in 2007, the pharmacists and multiple local cardiologists agreed upon a protocol for warfarin dosing adjustments based on recommendations from the American College of Chest Physicians. The collaborative practice agreement also contains protocols for the management of supratherapeutic international normalized ratio (INR) and bleeding episodes. Upon referral, the physician provides the pharmacy with the indication for anticoagulation and the desired therapeutic range for the INR.

The patient receives education on anticoagulation at the first visit and further education is guided by the experience and needs of the patient. Initial visits generally require 30 minutes to obtain the patient’s medication history and provide essential education on anticoagulation therapy. Follow-up visits usually take 15 minutes. Student pharmacists can be utilized in a number of ways, including patient education, performing finger sticks and running the INR test, and preparing the patient and physician letter at the conclusion of the visit.

The INR measurement is obtained using the CoaguChek XS device, which provides results from a finger stick in 1 to 2 minutes. By using this device, the patient is able to receive their results and dosage instructions at the time of their visit. In contrast, many medical offices utilize off-site labs, which perform venous blood draws to measure INR. The result is then reported to the medical clinic, which then usually calls the patient to provide instructions on continuing or changing the warfarin dose. Not only is this method of monitoring more invasive to the patient, there are more opportunities for communication barriers between the lab, the practitioner, and the patient.

When a patient visits the pharmacy for anticoagulation monitoring, the patient and physician immediately receive a document containing the results of the INR and directions for continuing or changing the dose of warfarin at the conclusion of the visit. The collaborative agreement between the pharmacists and physicians allows the pharmacist to make dose adjustments in the patient’s warfarin without prior approval from the physician.

Patients are generally seen every 4 weeks or sooner if the INR is out of the specified therapeutic range or dose adjustments are made. A follow-up appointment is scheduled at the conclusion of each visit; however, patients can be seen on a walk-in basis if the originally scheduled time is not convenient. Patients are charged a fee for each visit, which is comparable to an insurance copay in most instances.

As the medication expert on the health care team, the pharmacist is able to provide anticoagulation management to patients on warfarin therapy, which allows the physician to spend extra time with patients requiring more complex treatment. Through collaboration with health care providers throughout the community, the pharmacists at Buford Road Pharmacy have made a wide range of patient care services more accessible to thousands of patients.

Pharmacists as health care providers are placed in a unique position to provide valuable patient care services and to create meaningful relationships with patients. This business model is one example of how pharmacists can utilize their training to improve the patient care experience.

Sarah K. Milam, PharmD, is a pharmacist at Kerr Drug. She earned her doctor of pharmacy at the University of North Carolina at Chapel Hill.