An evaluation of the impact of the Lambeth PCN pharmacist anticoagulation skills development project
Authors: Shuker H , Kayyali R , Bhandary S , Collings V 
Published: November 2024

Abstract

Background
Atrial Fibrillation (AF) is a prevalent heart condition linked to significant morbidity and mortality due to its association with stroke.1 Despite the clear benefits of anticoagulation in reducing stroke risk, its underuse and suboptimal monitoring remain a concern.2

Aim
This study aims to evaluate the impact of a pharmacist-led training programme in Lambeth, London, focusing on improving pharmacists' competency and confidence in managing Direct Oral Anticoagulants (DOACs). It assesses if the training met pharmacists' needs, evaluates current monitoring patterns to determine if training was warranted, and identified areas for further training improvement.

Methods
The study involved 41 GP practices across 9 Primary Care Networks (PCNs) in Lambeth. Practices were eligible based on their involvement in the management of AF patients prescribed DOACs. All pharmacists at these practices who were actively engaged in anticoagulation management and willing to participate in pre- and post-training assessments were invited to take part. Recruitment involved direct communication through practice managers and emails detailing the study’s objectives and benefits.
DOAC monitoring data was extracted from patient medication records and subsequently compared to the South East London anticoagulation guidelines3 to establish compliance percentages. A competency assessment was conducted on pharmacists using a pre- and post-training checklist framework devised by the Consultant Anticoagulant Team at Guy’s and St Thomas’ NHS Foundation Trust (GSTT). The Wilcoxon signed-rank test analysed this paired data, with a p &lt; 0.05 set for statistical significance. Additionally, semi-structured interviews were conducted to gather insights on their training experience and perceptions. Transcripts were coded using NVIVO software to identify themes. Ethical approval was obtained from Kingston University London.

Results
Of the 2,987 AF patients across the 41 GP practices, 87.6% were on DOACs. Prescribing and monitoring trends were consistent across all GPs, with scope to improve compliance across all parameters, such as CHA₂DS₂-VASc score assessment prior to DOAC initiation. The competency assessment, completed by ten pharmacists, showed a significant improvement post-training, with mean scores rising from 3.3 to 4.1 (p&lt; 0.00001). Improvements were seen across all domains, particularly in explaining the rationale for anticoagulation, showing CHA₂DS₂-VASc and HASBLED scores, and discussing modifiable HASBLED factors. Competency in patient communication remained highest, while managing particular cases like reversal procedures and patients with cancer showed lower competency, indicating areas for training improvement. The interviews, conducted with ten pharmacists, revealed three main themes: (1) Confidence and competence in anticoagulant prescribing and optimisation, (2) Evaluation of the training programme's effectiveness, and (3) Professional growth and career development. Pharmacists reported greater confidence in managing DOACs post-training, though challenges remained in patient engagement and collaboration with GPs lacking DOAC knowledge.

Discussion / Conclusion
The evaluation proved a positive impact on pharmacists' competency and confidence in DOAC management. Suboptimal monitoring practices in Lambeth highlighted the need for this training programme and its crucial role in improving patient outcomes. Limitations include a small interview sample and potential biases in self-reported evaluations. A longitudinal study is recommended to assess long-term impacts. Ongoing training and systematic data collection are essential, and similar training should be extended to other healthcare professionals.

References
1. Nemati S, Ghassemi MM, Ambai V, Isakadze N, Levantsevych O, Shah A, et al. Monitoring and detecting atrial fibrillation using wearable technology. In: 2016 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) [Internet]. [cited 2024 Apr 17; IEEE; 2016. Available from: https://pubmed.ncbi.nlm.nih.gov/28269032/
2. Jones NR, Hobbs FR, Taylor CJ. Atrial fibrillation and stroke prevention: Where we are and where we should be. British journal of general practice [Internet]. 2018 Jun 1 [cited 2024 Apr 17]; 68(671):260-261. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29853572
3. Direct Oral Anticoagulant (DOAC) Initiation and Monitoring Guidance for Non- Valvular Atrial Fibrillation (AF) South East London Integrated Medicines Optimisation Committee (SEL IMOC) [Internet]. [cited 2024 Apr 17]. Available from: https://www.selondonics.org/wp-content/uploads/dlm_uploads/DOACs-FAQ-updated-January-2024-FINAL.pdf