Pharmacist Management of Oral Anticoagulation for Atrial Fibrillation in the Community The APOTHECARY AF Study

BACKGROUND We developed a novel, community pharmacy-based, pharmacist-driven atrial fibrillation (AF) stroke prevention model involving pharmacist prescription of oral anticoagulants (OAC) in Alberta, Canada. Generalizability to healthcare systems outside Canada is unknown. OBJECTIVE We recruited 5 California pharmacies for a proof-of-concept pilot study aimed at evaluating the prevalence of ‘actionable' AF and the feasibility, safety, and barriers to implementing a pharmacist OAC prescription program. METHODS Prior to implementation, pharmacist and physician stakeholders were surveyed to identify potential barriers. Pharmacists identified adults aged > 60 with CHADS-VASc score of ≥2 (men) or ≥3 (women), and ‘actionable' AF, defined as 1) untreated, 2) sub-optimally treated, or 3) inappropriately treated. Participants were enrolled in a 3-month intervention in which pharmacists optimized OAC. Participant satisfaction was assessed at 3 months. Safety endpoints were assessed at 6, 9, and 12 months. Pharmacist-reported implementation barriers were assessed at 1 and 3 months. RESULTS Actionable' AF prevalence ranged from 14% to 41%. 14 participants were enrolled. At baseline, 50% were untreated, and 50% were sub-optimally treated. At 3 months, 91% were on guideline-concordant OAC therapy. There were no major bleeding events and no prescription overrides. Participants reported high satisfaction with pharmacist services. Perceived barriers reflected reported implementation challenges: 1) lack of time, 2) insufficient access to medical records, and 3) adequate reimbursement. CONCLUSIONS Community-based, pharmacist-driven OAC prescription offers an opportunity to effectively close gaps in stroke risk reduction therapy for patients with AF. Scalability in the US will depend on policy and infrastructure changes that address implementation challenges.