2026 Southeastern Residency Conference

Pharmacist Impact on Quality of Anticoagulation Management: A Before and After Study

Edward McPartland, Victoria Burnette, Kelley Baxter, Chris Larkin
Ascension Saint Thomas Hospital West

Background/Purpose: Labile International Normalized Ratios (INR), defined as a Time in Therapeutic Range (TTR) less than 60%, has been identified as a key modifiable risk factor for adverse anticoagulation outcomes such as thrombosis or hemorrhage1. Prior evidence demonstrates that even modest improvements in TTR are clinically significant, as increases of 7% and 12% have been associated with the prevention of one major bleeding or thromboembolic event per 100 patient-years, respectively. Within the Ascension Saint Thomas Market (STM), there are several anticoagulation clinics, with Ascension Saint Thomas Hospital West being home to a pharmacist-managed clinic (PMC). In 2024, restructuring within the STM resulted in patients transitioning from one nurse-managed clinic (NMC) to our PMC. This transition provided an opportunity to evaluate clinical outcomes based on differences in clinic structure, such as clinic protocols and scope of practice. 
Methodology: This single-center retrospective chart review utilized electronic medical records to evaluate patients managed in the NMC from February 1, 2024 to July 31, 2024, and who were subsequently transferred to the PMC and received care from February 1, 2025 to July 31, 2025. Patients were identified via a transfer list organized by pharmacists during the transfer of care across clinics. Identified patients were reviewed using CoagClinic software for both timeframes, including documented visits and relevant laboratory values. Reports were generated for the specified time periods. Eligible participants were adults (≥ 18 years) who had their INR managed by a healthcare professional at both clinics within the specified timeframe. Patients were excluded if they were pregnant or incarcerated during the study. The primary outcome assessed the difference in TTR between the NMC and PMC. Secondary outcomes included extended TTR (±0.2 INR); peri-procedural bridging with a parenteral anticoagulant; bridging due to subtherapeutic INR; and hospital admissions due to hemorrhagic event, thromboembolic event, or supratherapeutic INR.
Results: A total of 347 patients were screened, of whom 294 met inclusion criteria. Mean TTR was significantly higher in the PMC compared to the NMC (68.2% vs 61.7%, p < 0.001), representing a 6.5% increase. Extended TTR was also significantly improved in the PMC (83.0% vs 75.5%, p < 0.001), corresponding to a 7.5% increase. A clinically significant reduction in hospital admissions due to hemorrhagic events was observed in the PMC compared to the NMC (4 vs 12 events, p = 0.07), although this difference did not reach statistical significance. There were no statistically significant differences in peri-procedural bridging therapy (8 vs 17 events, p = 0.10), subtherapeutic INR bridges (16 vs 8, p = 0.14), hospital admissions due to thromboembolic events (2 vs 2, p = 1), or hospital admissions related to supratherapeutic INR (2 vs 1, p = 1). Additional findings demonstrated significantly more clinic visits in the PMC (13 vs 11 visits, p < 0.001) and improved TTR among high-risk patients with INR goals outside the standard intensity of 2-3 (65.1% vs 56.7%, p < 0.01). Additionally, within the PMC cohort, 8 patients (2.7%) had documented changes to their INR goal during transition from the NMC.
Conclusions: Management within a PMC was associated with significantly improved TTR and extended TTR. Although secondary clinical outcomes did not reach statistical significance, a clinically meaningful reduction in hemorrhagic admissions was observed. The PMC also demonstrated more frequent clinic visits per patient, guideline-recommended goal INR updates, and improved TTR among high-risk patients with INR goal ranges outside of 2–3. These results highlight the potential of pharmacist-managed anticoagulation services to improve anticoagulation quality and facilitate tailored patient care.