Clinical Impact of the IHS Anticoagulation Training Program

1. 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

2. 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.

3. 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

4. ACCP CHEST Guidelines Ansell J, et. al. Pharmacology and management of the vitamin K antagonists: ACC Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):160S-198S. 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].”

5. 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

6. History • 3 programs offered in 1999 • Currently offer 4 programs/year • 351 attendees and 39 programs to date • 2 year waiting list

7. History

8. History

9. History

10. IHS Anticoagulation Training Program • Interactive, advanced, 3 day training • Didactic and practical components • Unique • Direct patient care • Outcomes database • provided • Historically, no cost to • participant except • travel Comes Standard • Continuing education • Lecture material and articles made available • Didactic lectures

11. 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

12. 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

13. SurveyMethods • Pilot phone survey • Validate survey • 3 attendees • 1, 5, 10 years ago • Modified survey • Disseminated survey via email • Collected data over 4 week period

14. Study Profile

15. Results:Participant Characteristics 97.8% - pharmacists

16. Results: Career Progression ATP Participation • 55% - Led to responsibility changes • 76% - Contributed to career progression

17. Results: Clinic Role

18. Miscellaneous Results 7 specialties • 21% - Helped them develop other clinics • 48 different clinics • 13 different specialties • 98% - Encourage ATP attendance for initial credentialing

20. 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

21. 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

23. Results of 2nd Aim Development of Anticoagulation Clinics 62% had ACC at facility at time of ATP attendance

24. Results of 2nd Aim Development of Anticoagulation Clinics Three most common barriers • 33% - Cost of dedicated personnel • 39% - Office Space • 47% - Lack of reimbursement

26. Results of 3rd Aim Anticoagulation Clinical Practices

27. 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

28. 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

29. 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

30. Survey Strengths • Good representation from each time period • High response rate • 70% sent survey, completed it • 57% of all trainees completed survey

31. 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?

32. Thank You! Nicholas Sparrow, Pharm.D. PGY1 Pharmacy Practice Resident Claremore Indian Hospital nicholas.sparrow@ihs.gov 918-342-6657