Anticoagulant Management for NVAF: Burden on Healthcare Systems - Episode 6
The Role of Anticoagulation Clinics
Gary M. Besinque, PharmD, FCSHP; Jaime E. Murillo, MD; Juvairiya Pulicharam, MD; Ralph J. Riello III, PharmD, BCPS; and Peter Salgo, MD, highlight the benefits of managing a patient with nonvalvular atrial fibrillation in an anticoagulation clinic.
Peter Salgo, MD: Let’s talk about anticoagulation clinics.
Juvairiya Pulicharam, MD: In our organization, we have an anticoagulation clinic. The pharmacists are the ones who are leading the anticoagulation clinic. When there are issues, we usually…
Peter Salgo, MD: He’s blushing.
Jaime E. Murillo, MD: Thumbs-up.
Peter Salgo, MD: I always say, and have said many times, that the day that we got monitoring in my intensive care unit was the day that our PharmDs started rounding with us. We actually understood what we were doing, for the first time.
Ralph J. Riello III, PharmD, BCPS: Who would have thought.
Peter Salgo, MD: Do the pharmacists typically manage these anticoagulation clinics?
Ralph J. Riello III, PharmD, BCPS: Yes.
Gary M. Besinque, PharmD, FCSHP: Yes.
Peter Salgo, MD: How do they work? Who gets notified when the INR [international normalized ratio] is too high or too low? How does all of that actually get put together?
Juvairiya Pulicharam, MD: There’s good collaboration. That’s what I’ve seen with the pharmacists who manage these patients, as well as the primary care physicians and the cardiologists.
Jaime E. Murillo, MD: We’re getting into a really opportunistic area here. This is where I think we have many opportunities among many healthcare organizations across the nation. Not everybody is that organized. I sometimes get a notification about the INR. “What should I do?” I’m in the midst of many other things. So, the lack of a team approach—that’s where we have a tremendous opportunity with the pharmacists, primary care physicians, and cardiologists. Later, we can discuss what role each should be playing. I think it’s extremely important. That’s where anticoagulation clinics, for instance, can preferably be managed better by someone with expertise—someone who takes the time to explain interactions and potential side effects to the patients. That’s the pharmacist. To be honest, the doctors don’t spend that time.
Juvairiya Pulicharam, MD: I just want to add that the pharmacists really take the time to see which patients may benefit from an anticoagulation method. They even educate the patient and seem to educate the primary care physicians. So, I think they’re a strong player in all sorts of medication reconciliation.
Peter Salgo, MD: When I was a house officer, we actually had a clinic. We had a warfarin clinic. Each of us had a day in the box. We had to be down there to look at it. Back then, it wasn’t INR. It was never fun. We all had clinic and other things to do. We were, as you said, distracted by 12 other things. It’s nice to have somebody who is focused on that. Is this something that pharmacists actually look forward to doing?
Ralph J. Riello III, PharmD, BCPS: Yes, certainly. We have an anticoagulation clinic rotation on both campuses at Yale. Our residents go through there and they’re overseen by a dedicated anticoagulation pharmacist on both campuses. They’re really not warfarin clinics now. We’re running a pretty good DOAC [direct-acting oral anticoagulant], serum creatinine shop, where we bring our patients back, especially the ones who we’ve converted from warfarin therapy over to a DOAC. We check their serum creatinine to make sure that their dose is still appropriate. We make sure that they’re still affording all of those copays and provide them with options for other payment programs that can help them get the drug cheaper, if we can.
Peter Salgo, MD: That sounds great, actually.