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 1

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. 2

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 3

4. ACCP CHEST Guidelines 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].” 4 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.

5. IHS Anticoagulation Training Program History 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 5

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

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

11. Anticoagulation Training Program Clinical 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 11

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 12

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

14. Study Profile 14 331 providers trained in the training program 268 participants sent survey 185 Surveys completed -1 participant sent survey had not completed ATP training -3 started but did not finish survey -79 did not take survey Exclusions: -13 ATP Faculty -2 had previously opted out with the survey instrument provider -48 participants with unknown e-mail addresses

15. Results: Participant Characteristics 15 97.8% - pharmacists

16. Results: Career Progression ATP Participation 55% - Led to responsibility changes 76% - Contributed to career progression 16 Practice SettingAt time of ATPCurrently Primarily Staffing45%21% Primarily Clinical26%34% Residency/Training16%3% Admin/Management8%23% Other5%19%

17. Results: Clinic Role Clinic RoleResponse % Care Provider26% Manager4% Both22% 17

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

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20. Results of 1 st Aim Confidence 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 20

21. Results of 1 st Aim Confidence 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 21

23. Results of 2 nd Aim Development of Anticoagulation Clinics outpatient New outpatient ACC or service ACC established before ATP? YES NO Developed 5%62% Implemented 11%53% Improved 80%37% 23 inpatient New inpatient ACC or service ACC established before ATP? YES NO Developed11%18% Implemented16%19% Improved27%15% 62% had ACC at facility at time of ATP attendance

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

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26. Results of 3 rd Aim Anticoagulation Clinical Practices 26 Integrate ACC outcomes into performance improvement ACC demonstrated improvement in outcomes since ATP attendance YES NO Don’t know Yes72%2%26% No25%31%44%

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 27

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 28

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 29

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

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? 31

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