Evaluation of the potential impact of pharmacy technician performance of anticoagulation clinic tasks on operational efficiency.

PURPOSE: Results of a study to determine the proportion of anticoagulation clinic workload that could be performed by clinical pharmacy technicians (CPTs) and the potential impact on operational efficiency of pharmacist-managed anticoagulation clinics (ACCs) are reported. METHODS: In a quality improvement project involving 11 Veterans Affairs (VA) medical centers, investigators conducted a 3-day time study in pharmacist-managed ACCs followed by scoring of task appropriateness for CPTs via the RAND/UCLA appropriateness method by the VA Anticoagulation Subject Matter Expert (SME) Workgroup. The primary outcome was the percentage of tasks deemed appropriate for a CPT to perform. RESULTS: The Anticoagulation SME Workgroup determined that a wide variety of mainly administrative ACC tasks could be completed by a CPT. At the 11 VA ACCs, an average of 53.4% (range, 39.9-76.1%) of tasks being performed by pharmacists were deemed appropriate for CPTs. The average percentage of total clinic time associated with performing tasks appropriate for a CPT equated to an estimated 1,111 hours per year. Shifting that portion of the annual work hours to a CPT could potentially result in cost avoidance of $55,302. CONCLUSION: At the ACCs evaluated, a significant proportion of tasks (53.4% on average) may be appropriate to assign to CPTs to improve the operational efficiency of these clinics. This finding supports development of business plans for the addition of CPTs in ACCs along with elements to inform crafting of an effective template for ACC structure, including clearly defined CPT roles.

Antithrombotic therapy in end-stage renal disease.

The delicate balance of risk vs. benefit of using antiplatelet and antithrombotic agents in the general population is well established. The decision to use these agents in the end stage renal disease (ESRD) population remains complex and difficult. The concomitant association of a prothombotic state with high risk of bleeding in the ESRD population requires individualization and careful clinical judgment before implementing such therapy. There remains a paucity of clinical trials and lack of substantial evidence in literature for safe and effective use of antithrombotic drugs in patients with advanced chronic kidney disease. The current review summarizes the pros and cons of using antiplatelet and antithrombotic agents in primary and secondary prevention of cardiovascular events, evaluate the risks with routine use of anticoagulation for cerebrovascular stroke prevention with nonvalvular atrial fibrillation and role of newer oral anticoagulants as alternate agents in the dialysis population.

Aldosterone receptor antagonists: focus on eplerenone.

Despite the development of hypertension treatment guidelines, blood pressure control in the general population remains inadequate, indicating the need for ongoing re-evaluation of treatment strategies to further improve blood pressure control. Hypertension results from alterations in cardiac output and/or peripheral resistance. The renin-angiotensin-aldosterone system may be responsible, at least in part, for these alterations. Despite pharmacologic intervention with angiotensin-converting enzyme inhibitors and angiotensin type-1 receptor antagonists, aldosterone continues to be produced. Therapeutic modalities for treating hypertension directed toward antagonizing aldosterone might more effectively control blood pressure. Eplerenone, a new selective aldosterone receptor antagonist, recently received approval from the US Food and Drug Administration for the treatment of hypertension, either alone or in combination with other antihypertensive agents. The objective of this review is to summarize the renin-angiotensin-aldosterone system, emphasizing the role for aldosterone antagonism in the management of hypertension, with a focus on eplerenone.