Effects of Ambulatory Clinical Pharmacy Anticoagulation Service on the Outcomes of Anticoagulation Knowledge

目的：評估門診藥師執行臨床藥事服務的成效，利用warfarin衛教單張或手冊教導使用warfarin患者後評估患者對抗凝血知識認知提升的情形，同時評估患者凝血酶原時間／國際標準凝血酶原時間比值變化之情形、血栓或出血而急診和住院的情形是否有改善。材料與方法：收納條件為可以中文或台語與藥師溝通之18歲以上且願意接受warfarin衛教的門診患者，經由藥師利用warfarin衛教單張或手冊衛教，患者在接受衛教前後受接受測驗，評估衛教執行成效，同時利用問卷調查來了解接受衛教患者的態度與意見，也了解患者接受衛教前6個月及接受衛教後6個月的INR值改變情形、血栓或出血而急診和住院的情形。結果：經由藥師臨床藥事服務，患者接受warfarin衛教後的平均分數明顯提升（p<0.001），患者的INR值在目標值的期間顯明增加（p<0.001），因血栓或出血而急診和住院的情形大幅減少（p<0.001）。結論：此研究結果顯示經由藥師介入的門診臨床藥事服務，warfarin衛教成效顯著，患者接受warfarin衛教後的分數明顯增加，患者INR值在目標值的期間顯明增加，因血栓或出血而急診和住院的情形大幅減少。Objective: The objective of this study was to assess patient knowledge of anticoagulation improvement using a patient education sheet or booklet about warfarin provided by clinical pharmacy anticoagulation service (CPAS). We investigated whether the material was helpful to these patients, whether it improved prothrombin time (PT)/ international normalized ratio (INR) monitoring status, and whether it reduced emergency department (ED) visits and hospital admissions for hemorrhage and thromboembolism. Materials and Methods: We included patients aged 18 years old and above who could communicate in Mandarin Chinese or Taiwanese with a pharmacist, who were willing to receive warfarin education, and willing to participate in this study. Patients received tests before and after receiving warfarin patient education. To evaluate patient's attitude and opinion, we administered questionnaires after they completed the education program. We also investigated INR monitoring status, ED visits, and hospital admissions for hemorrhage and thromboembolism events during the 6 months prior to before the education program and also followed-up for 6 months after completing the CPAS program. Results: After CPAS, average scores were found to have significantly increased (p<0.001). Days within INR target improved significantly and days below INR target and days above INR target decreased significantly (p<0.001). The number of hemorrhage and thromboembolism events requiring ED visits and hospital admissions decreased significantly (p<0.001). Conclusion: Clinical pharmacy services in the ambulatory clinic systems of this health system had a positive effect on outcomes. After pharmacist-directed CPAS program, average outcome scores were increased significantly with regard to usage of warfarin and similar medications. Patients achieved their target INR ranges significantly more often after CPAS care and had fewer ED visits and hospitalizations due to thromboembolism and hemorrhage events.