Pharmacist-managed Warfarin in Pediatric Cardiac Patients: Quality-improvement Study

Objective: To compare the efficacy of warfarin management by a pharmacist-managed group to a cardiologist-managed group (usual care) in an outpatient pediatric population. Methods: Fourteen patients with an international normalized ratio (INR) goal determined by a cardiologist were included. The pharmacist-managed group included twelve patients. There were seven patients in the cardiologist-managed group. Prior to the transition to a pharmacist-managed service in September 2014, cardiologists managed anticoagulation. For the cardiologist-managed group, INR values were recorded for six months. Following a washout period of three months, INR values were obtained for the pharmacist-managed group for the subsequent six months. Patients were included in each analysis if they were followed for more than 3 months. A protocol guided dose adjustments, recommended monitoring, and allowed for pharmacist-managed warfarin. Results: The median number of INR tests per patient was not significantly lower in the cardiologist-managed group compared to the pharmacist-managed group (28 versus 36 measurements, p=0.06). The median percentage of time in therapeutic range using the Rosendaal method was not significantly higher in the pharmacist-managed group compared to the cardiologist-managed group (55.5% versus 54%, p=0.93). The median percentage of values in therapeutic range using the traditional method was also not significantly higher in the pharmacist-managed group compared to the cardiologist-managed group (41.9% versus 36.8%, p=0.93). Conclusion: Warfarin management in a pharmacist-managed group compared to a cardiologist-managed group provided similar care. Differences in time in therapeutic range and median values in therapeutic range were not found between the pharmacist-managed group and cardiologist-managed group. These results describe and provide support that pharmacist-managed anticoagulation of pediatric cardiology patients is safe and effective in the outpatient setting.