Clinical Impact of the IHS Anticoagulation Training Program

USPHS Scientific and Training Symposium

May 2010

LT Nicholas Sparrow, Pharm.D.

PGY1 Pharmacy Practice Resident

Claremore Indian Hospital

Claremore, Oklahoma

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Disclosure Statement

The opinions expressed in this presentation are those of the authors and do not necessarily reflect the views of the Indian Health Service, Cherokee Nation, or University of Oklahoma Health Sciences Center.

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Objectives• Summarize the history and current status of the

Indian Health Service (IHS) Anticoagulation Training Program (ATP)

• Describe the study design and methods used to determine the impact of the ATP

• Describe participant perceptions about the impact of the ATP with respect to:– Confidence with anticoagulation management– Development and implementation of anticoagulation clinics

(ACCs) and services– Anticoagulation clinical practices

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ACCP CHEST Guidelines

Pharmacology and Management of the Vitamin K Antagonists

“4.1.1. For health-care providers who manage oral anticoagulation therapy, we recommend that they do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dosing decisions as occurs in an anticoagulation management service (AMS) [Grade 1B].”

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IHS Anticoagulation Training ProgramHistory

• Developed in 1999

• Lack of formalized training – Available programs had limited availability

• George F. Archambault Foundation– Unrestricted educational grant

• First program offered April 1999– 5 pharmacists, 1 nurse– WA, OK, ND, WY, AK, TX

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History

• 3 programs offered in 1999

• Currently offer 4 programs/year

• 351 attendees and 39 programs to date

• 2 year waiting list

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History

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History

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History

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IHS Anticoagulation Training Program

Comes Standard• Continuing education• Lecture material and

articles made available • Didactic lectures

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• Interactive, advanced, 3 day training

• Didactic and practical components

Unique •Direct patient care•Outcomes database provided •Historically, no cost to participant except travel

Anticoagulation Training ProgramClinical Impact Survey

• Co-investigators– LCDR Ryan Schupbach, Pharm.D., BCPS, CACP

– Michael J. Miller, R.Ph, DrPH – The University of Oklahoma College of Pharmacy

– Donald Harrison, Ph.D – The University of Oklahoma College of Pharmacy

• University of Oklahoma counterparts key in survey design

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Survey Design

• Cross-sectional email survey

• Consent to participate

• Background information

• Evaluate 3 key areas:

– Confidence in anticoagulation management– Development and implementation of ACCs– Anticoagulation clinical practices

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Survey Methods

• Pilot phone survey– Validate survey– 3 attendees

• 1, 5, 10 years ago

• Modified survey

• Disseminated survey via email

• Collected data over 4 week period

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Study Profile

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Results:Participant Characteristics

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97.8% - pharmacists

Results: Career Progression

ATP Participation• 55% - Led to responsibility changes• 76% - Contributed to career progression

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Results: Clinic Role

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Miscellaneous Results• 21% - Helped them develop other clinics

– 48 different clinics– 13 different specialties

• 98% - Encourage ATP attendance for initial credentialing

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7 specialties

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Results of 1st AimConfidence with Anticoagulation Management

• For all statements, >82% agreed / strongly agreed

Highly Rated• Areas with >60% strongly agreeing

– Educating patients on comprehensive warfarin management adjustments

– In understanding of warfarin indications

• In anticoagulation management skills overall– 97% agreed / strongly agreed

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Results of 1st AimConfidence with Anticoagulation Management

Areas Needing Improvement• All areas relating to confidence in outcome

collecting, analyzing, and reporting

• Anticoagulation-related care improved overall in our ACC– 3% disagreed / strongly disagreed

– 12% neutral

– 39% agreed

– 45% strongly agreed

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Results of 2nd Aim Development of Anticoagulation Clinics

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62% had ACC at facility at time of ATP attendance

Results of 2nd Aim Development of Anticoagulation Clinics

Three most common barriers

• 33% - Cost of dedicated personnel

• 39% - Office Space

• 47% - Lack of reimbursement

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Results of 3rd Aim Anticoagulation Clinical Practices

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Conclusions

• 98% recommended ATP for initial credentialing

• 97% felt confidence in anticoagulation management improved

• 84% felt the anticoagulation management in their clinics improved

• ATP helped in the development of other disease management clinics

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Conclusions

• Those without an ACC developed rather than improved their ACC

• The majority of barriers to ACC implementation are financially related

• Those who integrated ACC outcomes into performance improvement were more likely to report improvement in ACC outcomes

• ATP needs to work on emphasizing outcomes collection and analysis

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Survey Weaknesses

• Recall bias– some attended over 10 years ago

• Most ATP faculty involved in ACCs

• Unable to survey 15% of trainees who met inclusion criteria

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Survey Strengths

• Good representation from each time period

• High response rate – 70% sent survey, completed it

• 57% of all trainees completed survey

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Clinical Training Programs

• The ATP was created to fill a need

• Many software training programs

• Not many clinical training programs

• Well established program?– Why not create a training program?

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Thank You!

Nicholas Sparrow, Pharm.D.

PGY1 Pharmacy Practice Resident

Claremore Indian Hospital

nicholas.sparrow@ihs.gov

918-342-6657

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