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ACCP Anticoagulation Training Program: A Developer's Perspective

Written by Henry Bussey

How did the concept for the Anticoagulation Traineeship begin?
While attending a meeting in Las Vegas , I sat at lunch with Sarah Spinler, Pharm.D. (from the Philadelphia College of Pharmacy) and Ann Wittkowsky, Pharm.D. (from the University of Washington ). Sarah asked me if I would consider taking some of their students on rotation in my anticoagulation clinic if they paid me to do so. Our clinic is in the private sector and Dr. Spinler indicated that they had no such clinic available to their students. Before I could answer, Dr. Wittkowsky spoke up and said that her school also would be interested in sending their students. I had been working on a number of projects with Robert Uzzo, RPh at Aventis Pharmaceutical and I approached him with the idea of his company supporting such a training program.

What were the main objectives for the traineeship?
There probably were 3 primary objectives:

  • To provide Pharm.D. students and pharmacists with an exemplary education and training program in anticoagulation and antithrombotic therapy
  • To introduce individuals to the structure and financial considerations in creating and growing an anticoagulation service.
  • To provide interested students and pharmacists with at least an introduction to key aspects of clinical research.

Outline the steps involved in establishing the program.
Funding: I had already established an anticoagulation clinic within a private hematology and oncology practice. This clinic was an essential resource in the establishment of the training program. I then explored the idea of having Sanofi-Aventis provide an educational grant to be used to help off-set the travel and living expenses for individuals coming to San Antonio for the program. In addition, funding was also provided to the clinic and to my employer (The University of Texas) to help reimburse services provided to the trainees. Currently, changes in the process of securing unrestricted educational grants from industry have placed the continued funding of this program in jeopardy.

Staff: Shortly before starting the traineeship, the clinic hired a full-time Pharm.D. (Lisa Farnett, Pharm.D.) who was a former student of mine. Dr. Farnett did a tremendous amount of work in refining the structure of the traineeship and creating a syllabus. Unfortunately, because pharmacists were not recognized as “providers” under Medicare, we could not bill adequately for our patient care services. Consequently, when Dr. Farnett left for another position a few years ago, we were unable to justify hiring a Pharm.D. to replace her. Rather, we have hired nurse practitioners (NPs) and physician assistants (PAs) and trained them to do what clinical pharmacists are trained and licensed to do. Because NPs and PAs have provider status under Medicare, Medicare will pay approximately three times a much for a patient visit with a NP or PA, compared to what Medicare will pay a clinical pharmacist.

Curriculum – syllabus: Here we attempted to provide a balance between didactic education and hands- on clinical training. We – and especially Dr. Farnett – identified several knowledge areas that needed to be covered. These knowledge areas include:

  • “Anticoagulation sciences” (an over-view of the body’s clotting systems and the medications used to treat or prevent blood clots)
  • Hypercoagulable states (an understanding of the various types of hypercoagulable conditions, the severity and prevalence of complications resulting from hypercoagulable conditions, and related information

In addition to those general topics, sections were also added on such areas as DVT/PE, Atrial Fibrillation, Acute Coronary Ischemia/MI, Stroke, Prosthetic Heart Valves, Stroke, etc.) For each topic, specific objectives and a series of study questions were created in order to help guide the trainee to focus on the more important information. One to three case scenarios are provided at the end of each section in order to give the trainee the opportunity to test their knowledge of the topic. The curriculum also includes a copy of the report of the most recent Chest Conference on antithrombotic therapy, a binder that contains the objectives and study questions as well as selected readings cataloged according to topic. Trainees also spend one half of each week day seeing anticoagulation patients. I meet with the trainees twice a week for about 1 hour each session to review a disease state/condition of the week with the objectives and study questions serving to guide the discussion.

What challenges did you face in establishing the program and how did you overcome them?
The two initial challenges were securing adequate funding and dealing with some restrictions that the State Board of Pharmacy had placed on out of state or foreign trainees at the request of the Colleges of Pharmacy in the state. I identified Sanofi-Aventis as a company that had an interest in sponsoring the program but the University’s usual overhead charges would have taken so much of the grant that we would have been able to accept only about one-half as many trainees. The American College of Clinical Pharmacy (ACCP) agreed to administer the grant at substantially less overhead. I elected to have ACCP administer the program in order to be able to accept more trainees with the same amount of money, and because I felt that ACCP would give the program greater national visibility. The restrictive policies of the State Board of Pharmacy prohibiting foreign or out of state pharmacists created an obstacle that was overcome through negotiations with Board members who eventually agreed to exempt our program from the restrictions.

Are there ongoing challenges that must continue to be addressed and if so, how are they being managed?
The challenges at the current time include:

  • Continued funding – this year we were able to secure only about 25% to 30% of the level of funding that has been provided in the preceding 7 years and that reduction in funding is threatening the continuation of the program.
  • Limited interaction with a clinical pharmacist – with the loss of Dr. Farnett, that means that we have a Pharm.D. in clinic only 2 afternoons of the week (rather than 5 days per week). As long as pharmacists are not recognized as providers by Medicare and other payers, the only other solution I see is to try to incorporate more anticoagulation studies into my research activities (at a location different than the anticoagulation clinic) so that I can involve trainees by having them work with me directly on anticoagulation clinical trials. Until such a change can be solidified, we will have to rely on the NPs and PAs in the clinic providing a good deal of the hands-on clinical supervision of the trainees.

Please discuss the creation of m and explain its role in student education.
ClotCare was created independently of the anticoagulation clinic (as was the clinical research center that I mentioned in the question above). At about the same time that Bristol Myers Squibb took over Coumadin and stopped making patient education materials available, my youngest daughter was finishing her Information Technology (IT) training at the University of Texas. I was discussing our problem of patient education with her one day and she suggested that we establish a website to provide the patient education information to warfarin patients anywhere. Initially, that was the focus of the website, but as I realized that there was more and more new information being published in this area – and that there was no central clearinghouse for such information – we recognized a need to expand the website to become a more comprehensive information resource for all aspects of anticoagulation and antithrombotic therapy. The website added an editorial board of approximately 18 world-class experts and created a searchable database into which we could enter summaries of new studies and frequently asked questions for both clinicians and patients. Currently the website maintains a listserv of approximately 2,500 subscribers (to whom we send out 1 to 3 information alerts per month) and responds to approximately 100 questions per month. The traffic to the site is at least 130,000 per month and has approached a high of approximately 250,000 hits in a single month. The students often search the database for the most recent studies on a given condition and I sometimes will invite the students to write up an information summary of a new study. Such write-ups are entered into our database and they are included in the next information alert sent to subscribers . These write-ups also constitute a legitimate online publication for the students.

Entrepreneurship requires the ability to recognize and fulfill a professional obligation to promote change, to identify and pursue opportunities for the purpose of improving patients’ quality of life. How does the implementation of this program embody the spirit of entrepreneurship?
The anticoagulation clinic has clearly improved the quality of care – and therefore the clinical outcomes – of patients managed in this clinic. However, we are now attempting to test an entirely new approach to patient management that will involve self-testing and automated online monitoring. (Refer to the poster presented at the ACCP Annual Meeting on October 15, 2007, available under “Tools” on DELTA Rx ). The lack of provider status for clinical pharmacists (as discussed above) has prevented us in our setting from being able to hire additional PharmDs. Consequently, this training program trains individuals to provide optimal anticoagulation management, yet we cannot afford to hire these individuals in our own clinic because of the reimbursement issue. I have lobbied congress to pass legislation to give pharmacists provider status under Medicare and I have encouraged our professional organizations to be more active in this area. To date, the progress in this area has been disappointing. Currently, I am exploring another patient care model that would not be dependent on Medicare reimbursement but rather would be supported by direct payments from patients for those who value and choose such a service model. It is my hope and expectation that establishing such a service that is supported by patients “out of pocket” will result in an ever increasing number of patients who will demand that their insurance providers cover such a service. Further, if the new care model can demonstrate superior anticoagulation control and reduced complications while reducing costs; then we will have data to utilize in securing coverage for this new patient care model.

What advice do you have for students who are interested in participating in this type of program?
I would encourage students in this type of program to try to get the most that they can from the experience. Maintain an enthusiastic and aggressive attitude toward learning as much as possible, ask questions…always, don’t hesitate to challenge the preceptor and make him/her adequately explain or defend any position that is not consistent with what you may have learned or read elsewhere, look for opportunities to go beyond the requirements; do and learn more than is required.

What advice do you have for pharmacists who are interested in initiating a new educational program at their site?

  • Consider if the demand for such a program is adequate to justify the time and effort that will have to go into planning, developing, and promoting the new educational program.
  • Is the demand – and therefore the applicant pool – likely to continue through the near future? Otherwise, a lot of time and effort may be expended creating a training program that may become obsolete soon after it is established.
  • Consider what resources (including personnel) are available to participate in the program and to what extent will demands of the program pull the preceptor away from other priorities – possibly other priorities that are essential to the longevity of his/her own position.
  • What type of students will be attracted to the program? The anticoagulation traineeship has consistently attracted students who rank at the top of their class and are very motivated. Such students typically are bright, eager to learn, and engaging. Such trainees are considerably more fun to work with than the “average” student.