PHARMACEUTICAL CARE

Patient and Physician Satisfaction With a

Pharmacist-Managed Anticoagulation Clinic:
Implications for Managed Care Organizations
MCOs should consider adding pharmacist-managed anticoagulation clinics to the benefits
of their members because both patients and physicians show a high level of satisfaction.

ABSTRACT macist; and they had adequate time their anticoagulation therapy8 and
Purpose: To evaluate both patient during their appointments. Of physi- probably increased patient compli-
and physician satisfaction with a cian questionnaires, 51.2 percent ance. In addition to patient compli-
pharmacist-managed anticoagula- were returned. Their most positive ance, anticoagulation pharmacists
tion clinic utilizing a fingerstick responses were that their patients also assist in improving patients’
method of obtaining blood and preferred fingerstick to venipuncture control of warfarin, as evidenced by
point-of-service testing. and that the information from the a greater percentage of prothrombin/
Design: The patient questionnaire pharmacist was timely and com- international normalized ratio
consisted of nine Likert statements plete. (PT/INR) levels within therapeutic
concerning their experiences with Conclusions: Both patients and range 9 and preventing potential
the clinic. The physician question- physicians appear to have high lev- harmful drug-drug or drug-food in-
naires consisted of five Likert state- els of satisfaction with a pharmacist- teractions1. One study indicated that
ments regarding their perception of managed ambulatory anticoagulation a pharmacist-managed anticoagula-
the clinic. clinic. Managed care organizations tion clinic may provide more effi-
Methodology: We mailed the pa- should consider adding pharmacist- cient tracking of PT/INR levels than
tient questionnaire and a self-ad- managed anticoagulation clinics to traditional physician management of
dressed stamped envelope to all pa- their members’ benefits. anticoagulation10.
tients who had utilized the services Although there is considerable lit-
of the clinic. We faxed the physician INTRODUCTION erature supporting the clinical ad-
questionnaire to all physicians with It has been established that phar- vantages of pharmacist-managed an-
patients attending the clinic. We an- macist-managed anticoagulation ticoagulation services, there are
alyzed the responses using Cron- services can prevent warfarin-related limited studies of patient and physi-
bach’s alpha to determine reliability. hospital admissions and improve the cian satisfaction with pharmacist-
Principal findings: Of patient ques- overall quality of patient care.1,2,3 managed anticoagulation clinics.
tionnaires, 79.0 percent were re- Careful management of warfarin
turned. The most positive responses therapy has been associated with de- METHODS
were that the patients preferred creased warfarin-related hospital Clinic description
fingerstick to venipuncture; they ap- readmissions, length of stay4,5 and The outpatient anticoagulation
preciated having their appointments warfarin-related complications such clinic used in this study was associ-
kept on time; they trusted the phar- as major hemorrhages and throm- ated with a not-for-profit hospital in
boembolic events6,7. Patient educa- Pueblo, Colo., a city with a popula-
tion by pharmacists in clinics has im- tion of approximately 100,000. This
AUTHORS proved patients’ understanding of clinic opened in September 1997.
Algha D. Lodwick, R. Ph., The patients were referred by physi-
is an anticoagulation pharmacist cians from either inpatient or outpa-
at St. Mary-Corwin Medical Center, This paper has been peer- tient services. Physicians’ referrals
Pueblo, Colo. reviewed by appropriate were voluntary, not mandated under
Terrie A. Sajbel, Pharm.D., members of of MANAGED CARE’S any contract or other agreement. Pa-
is a clinical pharmacist at Colorado Editorial Advisory Board. tient appointments were scheduled
Mental Health Institute at Pueblo. for a half hour. This provided the
At the time the article was written, This research was supported by pharmacist adequate time to meet
she was director of pharmacy an unrestricted grant from with the patient and to enter a report
services for St. Mary-Corwin Med- SC Ministries Inc. of Cincinnati, of the visit in a computer and fax it
ical Center, Pueblo, Colo. previously known as to the patient’s physician(s). At each
Sisters of Charity. appointment the pharmacist and the
patient discussed current warfarin

FEBRUARY 2000 / MANAGED CARE 47

 SATISFACTION WITH A PHARMACIST-MANAGED ANTICOAGULATION CLINIC

dosage schedule, adverse reactions, patient survey consisted of a series of pendix B. We faxed them to the of-
medication changes, and whether nine Likert statements with choices fices of 21 family practitioners, seven
the patient missed any doses of war- ranging in value from 1 (“strongly cardiologists, and seven internists
farin. The pharmacist monitored disagree”) to 5 (“strongly agree”) and who had patients enrolled in the
PT/INR level using a fingerstick to a section to write comments. These clinic. The responses were anony-
obtain 10µL of capillary blood. The are in Appendix A. One additional mous, and we did not collect demo-
pharmacist then tested the blood question asked respondents about graphic information on the respon-
with the CoaguChek system using frequency of emergency department dents.
nonhuman thromboplastin; the re- use. To keep the responses anony- We asked physicians to return the
sulting PT/INR was available within mous, we did not ask for demo- survey via facsimile, mail, or inter-of-
two minutes. The pharmacist then graphic information. There were no fice mail. We took no follow-up
showed the patient a chart with his follow-up measures. The question- measures.
past and current INRs, warfarin naires were mailed to every patient We then conducted descriptive
dosages, and the desired INR range. attending the Anticoagulation Clinic statistical analyses using the patient
The pharmacist gave the patient ed- as of Dec. 4, 1997. (One patient was and physician responses. Cronbach’s
ucational materials, and they dis- excluded because he could read nei- alpha, a measure of reliability, was
cussed them.11 The patient’s physi- ther English nor his native Spanish.) calculated for each of the surveys.
cian had authorized the pharmacist During May 1998, we drafted a Analyses were performed using Mi-
to adjust warfarin doses according physician satisfaction survey for the crosoft Excel (Redmond, Wash.) or
to a protocol. pharmacist-managed ambulatory SAS Version 6.12 (Cary, N.C.).
anticoagulation service. This survey
Survey methods consisted of a series of 5 Likert state- RESULTS
We developed two instruments to ments with choices ranging in value Patient satisfaction survey
measure the satisfaction of patients from 1 (“strongly disagree”) to 5 We mailed 44 patient satisfaction
and physicians with the pharmacist- (“strongly agree”) and a section to forms. One was returned to us be-
managed anticoagulation clinic. The write comments. These are in Ap- cause its address was incorrect; an-
other came back blank. Thirty-four
usable forms were returned, for a re-
Appendix A
sponse rate of 79.0 percent. An
CLINICAL PHARMACY ANTICOAGULATION SERVICE analysis for reliability using Cron-
Patient Satisfaction Survey bach’s Alpha yielded a reliability co-
efficient of 0.86.
Please circle the number that best describes how you feel. The mean responses to the survey
are shown in Table 1. The questions
1. Since I have been coming to the “Coumadin Clinic,” I understand my whose answers indicated a high
medications better than before. level of agreement were that finger-
(Respondents answered all questions (except No. 6) using this scale.) stick is the preferable test, that ap-
Strongly Agree Neither agree Disagree Strongly pointments were kept on time, that
agree somewhat nor disagree somewhat disagree
the clinic pharmacist’s response to
5 4 3 2 1
medication questions was trusted,
2. I prefer having my blood tested by using one drop rather than the
and that there was adequate time to
previous method.
discuss concerns. All had mean val-
3. The printed materials given to me have been helpful.
ues greater than or equal to 4.7.
4. The appointments with the pharmacist have been kept on time.
The only question with a mean
5. The parking for the clinic is convenient.
score below 4 was for parking, with
6. I have had to go to the emergency room ______ times since I have been
a score of 3.79 + 1.24. Scores for all
coming to the “Coumadin Clinic.”
other questions were remarkably
7. I feel less anxious about my medications since I have been coming to
high. The only question besides park-
the “Coumadin Clinic.”
ing that had a mean value of less
8. If I have a question about my medications, I would trust an answer
than 4.5 was the question about feel-
from the “Coumadin Clinic” pharmacist.
ing less anxious about their medica-
9. There is adequate time during my appointment at the “Coumadin
tions, which had a mean value of
Clinic” to discuss my concerns with the pharmacist.
4.37 + 0.85.
10. The “Coumadin Clinic” has assisted me to live the best quality of life
Additional written comments pro-
possible, given my medical conditions.
vided by patients were all positive
toward the clinic. Eight patients pro-
Write any further comments on the back of this sheet.
vided written comments regarding

48 MANAGED CARE / FEBRUARY 2000

 SATISFACTION WITH A PHARMACIST-MANAGED ANTICOAGULATION CLINIC

the clinic. Examples of comments in-

clude: “… they have time for me and Appendix B
my concerns”; “… it’s a wonderful CLINICAL PHARMACY ANTICOAGULATION SERVICE
plan — please keep it going”; “I feel Physician Satisfaction Survey
less anxious about … my Cou-
madin”; and “This is the first time I Please return by fax, inter-office mail, or U.S. mail.
have been regulated since 1991.”
1. My patients understand Coumadin better since they have been going to
Physician survey the St. Mary-Corwin Anticoagulation Clinic.
Of the 41 questionnaires faxed to (Respondents answered all questions using this scale.)
the physicians’ offices during May Strongly Agree Neither agree Disagree Strongly
1998, 21 were returned, for a re- agree somewhat nor disagree somewhat disagree
sponse rate of 51.2 percent. The re- 5 4 3 2 1
sponses were analyzed for reliability
using Cronbach’s Alpha. This yielded 2. My patients prefer having their blood drawn by fingerstick rather than
a reliability coefficient of 0.87. venipuncture.
The mean responses for each 3. The Anticoagulation Clinic has decreased the amount of time I spend on
question are shown in Table 2. No Coumadin patients.
question had a mean response less 4. The information I receive from the Anticoagulation Clinic is timely and
than 3.50. The statements drawing complete.
the highest levels of agreement were 5. The Anticoagulation Clinic has promoted positive outcomes in my pa-
that the anticoagulation clinic infor- tients.
mation was timely and complete,
that the patients preferred the finger- Do you have any other comments that you would like to share concerning
stick method of testing, and that the the Anticoagulation Clinic?
clinic decreased the amount of time
physicians spend on these patients. pharmacists suggest that offering per- pharmacist.
The statements with lower levels of sonal service and convenience are A notable finding is the high de-
agreement were that the clinic pro- important to consumers. 13,14 Be- gree of physician satisfaction with
moted positive outcomes in patients cause the anticoagulation pharma- the service, since physicians are
and that patients understood their cist in the current study had suffi- often uncomfortable delegating such
medications better. cient time to spend with patients and important activities. It appears that
was located in a building with con- the physicians referring patients to
DISCUSSION venient patient access, it is not sur- this specific anticoagulation service
The results of this study suggest prising that patients were satisfied are satisfied with the results to date.
that this pharmacist-managed anti- with the service. One must keep in mind that these
coagulation clinic is associated with Overall, the high response rate to physicians are probably biased be-
high levels of both patient and physi- both the patient and physician sur- cause they referred patients on a vol-
cian satisfaction. Both patients and veys indicates that there were posi- untary basis.
physicians appear to be satisfied with tive sentiments among both groups. The response with the highest
the pharmacist’s ability to provide The fact that 21.2 percent of the pa- mean score from the physician sur-
accurate and timely information re- tients and 52.4 percent of physicians vey was that the patients prefer
garding coagulation status. Patients wrote positive comments also fingerstick to venipuncture. This was
also stated they preferred the finger- demonstrates that both groups hold not surprising, because it was the
stick method of obtaining blood the pharmacist-managed anticoag- strongest response from patients.
samples to traditional venipuncture. ulation clinic in high regard. One third of the responding physi-
The results of this study are con- These responses show that the pa- cians strongly agreed that their pa-
sistent with a previously reported tients feel strongest about having a tients understand warfarin better
study examining pharmacist man- fingerstick rather than a venipunc- after attending the clinic. In addition,
aged anticoagulation clinics.12 In ture. They also feel strongly about 38 percent strongly agreed with the
that study, Schueler and Kaden re- having their appointments kept on statement that the anticoagulation
ported that patient satisfaction of a time. The other two strong responses clinic is promoting positive out-
pharmacist managed anticoagula- indicate that patients trust the infor- comes in their patients.
tion clinic in a tertiary medical cen- mation that they get from the anti- As with any research, this study
ter was “favorable,” although more coagulation clinic pharmacist and has limitations that the reader should
specific results were not reported. appreciate being given enough time keep in mind when interpreting the
Other studies of satisfaction with to discuss their concerns with the results. First, no attempt was made to

FEBRUARY 2000 / MANAGED CARE 49

 SATISFACTION WITH A PHARMACIST-MANAGED ANTICOAGULATION CLINIC

2 Pubentz MJ, Calcagno DE, Teeters JL.

Improving Warfarin Anticoagulation
TABLE I Patient Responses to in a Community Health Setting.
Pharmacist-Managed Anticoagulation Clinic Satisfaction Survey Pharm Pract Manage Q 1998;18:
1–16.
Question N Mean S.D. 3 Kroner BA. Anticoagulation Clinic in

Q1. Understand medications better 33 4.58 0.71 the VA Pittsburgh Healthcare Sys-
tem. Pharm Pract Manage Q 1998;
Q2. Use of fingerstick preferable 33 4.88 0.42 18:17–33.
Q3. Printed materials helpful 32 4.59 0.71 4 Garabedian-Ruffalo SM, Gray DR, Sax
Q4. Appointments on time 33 4.82 0.64 MJ, et al. Retrospective evaluation of
Q5. Parking convenient 33 3.79 1.24 a pharmacist-managed warfarin an-
Q7. Less anxious about medications 30 4.37 0.85 ticoagulation clinic. Am J Hosp
Q8. Trust the pharmacist 33 4.79 0.55 Pharm 1985;42:304–308.
5 Witt DM, Lyons E. Beall DG, et al. A
Q9. Adequate time during appointment 33 4.73 0.63
Q10. Assisted in providing best quality controlled retrospective evaluation
of a clinical pharmacy anticoagula-
of life given existing medical tion service. Pharmacotherapy
conditions 31 4.68 0.65 1996;16(3):514.
6 Bussey HI, Rospond RM, Quandt CM,
Response choices ranged from 1 = strongly disagree to 5 = strongly agree.
et al. The safety and effectiveness of
Q6 was not a Likert statement and was not tabulated. long-term warfarin therapy in an an-
ticoagulation clinic. Pharmacother-
apy 1989; 9(4);214–219.
TABLE II Physician Responses to 7 Wilt VM, Gums JG, Ahmed OS, et al.
Pharmacist-Managed Anticoagulation Clinic Satisfaction Survey Outcome analysis of a pharmacist
managed anticoagulation service.
Question N Mean S.D. Pharmacotherapy 1995; 15(6): 732–
Q1. Patients understand Coumadin better 20 3.50 1.32 739.
8 Piwowar N, Pierce W, Zaowitz BJ, The
Q2. Patients prefer fingerstick to
impact of an inpatient pharmacist-
venipuncture 19 4.47 0.70 based warfarin teaching program on
Q3. The clinic has decreased the amount patient understanding and satisfac-
of time spent on Coumadin patients 20 4.2 1.36 tion. Pharmacotherapy 1996;16(3):
Q4. Information from clinic timely 515
and complete 21 4.19 1.07 9 Conte RR, Kehoe WA, Nielson N, et al.

Q5. Clinic has promoted positive Nine-year experience with a phar-

patient outcomes 20 3.85 1.27 macist-managed anticoagulation
clinic. Am J Hosp Pharm 1986;43:
Response choices ranged from 1 = strongly disagree to 5 = strongly agree 2460–2464.
10 Wilson-Norton, JL, Gibson DL. Estab-

determine the extent of nonresponse should consider adding payment for lishing an outpatient anticoagula-
tion clinic in a community hospital.
bias. Because the surveys were pharmacist monitoring of warfarin Am J Health-syst Pharm 1996;53:
anonymous, it was impossible to tar- to their members’ benefits. Others 1151–1157
get persons who had not returned have demonstrated that pharmacist- 11 A Patient’s Guide to Using Coumadin.
the survey. However, the response managed anticoagulation clinics are Wilmington, Du Pont Pharma,
rates obtained in this study were re- effective, and we have shown that 1996.
markably high, 79.0 percent for pa- patients and physicians are satisfied 12 Schueler KR, Kaden TA. Quality as-

tients and 51.2 percent for physi- with them. sessment of a pharmacist managed
cians. Another limitation of this study The authors acknowledge the anticoagulation clinic. ASHP Mid-
year Clinical Meeting. 28(Dec): P-
was the small sample size — 34 pa- assistance of Ann Lodwick, M.A.,
327(D). 1993.
tients and 21 physicians. The results Mack Thomas, Ph.D., Daniel C. Mal- 13 Ludy JA, Gagnon JP, Caiola S. The pa-
of this study are also limited to this one, Ph.D., and Trang T. Than, tient-pharmacist interaction in two
particular clinic and pharmacist. Pharm.D. ambulatory settings: it’s relationship
Other results may be obtained in to patient satisfaction and drug mis-
other settings or with different phar- use. Drug Intelligence and Clinical
NOTES Pharmacy 1977;11:81–89.
macists. Nonetheless, pharmacists
14 Fincham JE, Wertheimer AI. Predictors
have consistently demonstrated the 1 Lee, YP, Schommer JC. Effect of a phar-
ability to appropriately monitor pa- macist-managed anticoagulation of patient satisfaction with phar-
clinic on warfarin-related hospital macy services in a health mainte-
tients who receive anticoagulation nance organization. Journal of
therapy. admissions. Am J Health-Syst Pharm
Pharmaceutical Marketing and
1996;53:1580–1583.
Managed care organizations Management 1987;2:73–88.

50 MANAGED CARE / FEBRUARY 2000