A small sub-study was also proposed to investigate an alternative model of care in an attempt to augment the role of community pharmacy in the service. It was planned that, under this model, the HMR visit would be supported by in- pharmacy POC INR monitoring rather than additional home visits. Patients who were regular customers of one of the pharmacies involved would be preferentially recruited into the sub-study, according to the study methodology previously outlined. They would receive the first home visit within two to three
107 days post-discharge as per the original model, but the additional visits (Visits 2
and 3) would be replaced by an INR monitoring service via the patient’s
community pharmacy. After Visit 1, the accredited pharmacist would provide the pharmacy with the patient’s INR result, the date of their next required INR and any pertinent history pending receipt of the final HMR report. The community pharmacist would liaise with the patient regarding a convenient time for INR monitoring (via an appointment system, if necessitated by the busyness of the pharmacy; alternatively, the patient could attend the pharmacy any time on the given day). The pharmacist would then be responsible for
reporting the INR result to the patient’s GP and liaising with them regarding the
necessity for dose adjustment, and the timing of subsequent INRs. Additional follow-up warfarin education was to be provided at this time as required. If a patient was unable to visit the pharmacy due to mobility or transport issues, or if their pharmacy was unable to offer the POC INR monitoring service on a given day for any reason, then the patient was to receive Visits 2 and 3 as home visits as per the original model.
Two sites were selected for inclusion in the sub-study - north-western Tasmania, and the area of Sydney surrounding CRGH. North-western Tasmania was chosen for logistical reasons due to the limited number of accredited pharmacists in this region and the sometimes large distances that the accredited pharmacists were potentially required to travel. The CRGH site was selected to allow the model to be trialled in a metropolitan as well as a regional setting.
Letters of invitation were posted to all pharmacies in north-western Tasmania and an owner of several pharmacies in Sydney in mid-March 2009. Three pharmacies in north-western Tasmania subsequently expressed an interest in being involved. One of these pharmacists subsequently withdrew, citing workload issues and the time commitment required for the training (i.e. completion of the Anticoagulation Education Modules) as the reasons for his
withdrawal. The owner’s Sydney pharmacies proved not to be within the CRGH
catchment area so were not viable options. The NWRH Information Evening (where both the original model and the sub-study were discussed), and the subsequent pharmacist training evening at the end of July, resulted in another two pharmacies agreeing to participate in this facet of the study. After the CRGH
108 Information Evening, four additional pharmacies in the local area whose pharmacists had attended the evening were personally approached and invited to participate. All four expressed an interest in participating, however one was chosen for involvement due to the difficulties in patient recruitment into the intervention arm of the study at the CRGH site. This pharmacy was specifically chosen as it was located on the hospital grounds and therefore it was proposed that patients would be able to have their INR checked at this pharmacy when they attended the hospital for other appointments.
Pharmacists from the volunteer pharmacies were posted the Anticoagulation Education Program previously disseminated to the accredited pharmacists involved in the main stream of the study, as described in Section 2.4.2 above. Representatives of three of the north-western Tasmanian pharmacies attended the hands-on training session in POC INR monitoring and the study methodology on 30 July, and the pharmacists from the fourth pharmacy were trained on site by the local project officer in August. The Sydney pharmacy was trained on site by the Sydney project officer on 11 November 2009. Standard operating and QC procedures were provided in the form of the “Implementation
Toolkit for Point-of-Care INR Monitoring Services in Community Pharmacies”
developed as part of the Small Project Grant 2008-203 under the Rural Pharmacy Workforce Program. The table of contents of this manual is displayed in Appendix M. The same QC plan that was used in the main arm of the study was to be applied to the monitors involved in the sub-study (as described in Section 2.5), and remuneration offered for each INR performed. The pharmacies whose pharmacists volunteered and were trained for involvement in the sub-study are detailed in Table 19.
Table 19. Pharmacies involved in the sub-study.
Pharmacy Name Location
Wilkinson's Pharmacy Burnie, Tasmania
Dixon's Pharmacy Wynyard, Tasmania
Healthpoint Pharmacy Wynyard, Tasmania
Coventry’s Pharmacy Latrobe, Tasmania
109 Unfortunately, due to recruitment issues at the NWRH and CRGH sites, no patients were recruited into the sub-study.