Can clinical pharmacists utilize telehealth to double the safety and efficacy of oral anticoagulation while reducing health care costs and improving patient satisfaction in patients with atrial fibrillation?

Background Published reports from the United States and New Zealand have described excellent control of the international normalized ratio (INR) and improved patient satisfaction in warfarin-treated patients whose therapy was managed by clinically trained pharmacists using point of care (POC, or "fingerstick") blood testing and online technology. This report examines the projected impact of such management on clinical outcomes and health care costs by using previously published information which quantified the relationships between anticoagulation control and rates of thromboembolism, major hemorrhage, and death. Methods Anticoagulation control was defined as the percent of time that the INR was within the target range (TTR). Published regression equations and adjusted relative risks were used to calculate the rate of thromboembolism, major bleeding, and death associated with various TTR values. The rates of ischemic stroke, myocardial infarction, intracranial hemorrhage, gastrointestinal bleed, and death, and the cost for each type of event, were used to determine a key composite end point rate and associated costs at various TTR values and as reported in the four direct-acting oral anticoagulant (DOAC) studies. Results Both the US and New Zealand online systems achieved comparable TTR values of approximately 75% (or better). Cost avoidance per 1000 patients per year based on projected key composite end point rates at a TTR of 75% ranged from $10.4 million compared with a TTR of 30% to $2.2 million compared with a TTR of 65%,. Cost avoidance compared with the rates reported in the DOAC trials ranged from $1.4 to $4.5 million. Patient satisfaction scores exceeded 90% with both systems as reported previously. Conclusion Clinically-trained pharmacists using POC INR testing and online management may reduce major clinical events by more than 50%, substantially reduce health care costs, and improve patient satisfaction. Data from Europe confirm that these low projected event rates are achievable.