Dobrzanski, S. and Shaw, Nicola (2009) An audit to determine if general practitioners are aware of warfarin treatment when this drug is routinely provided by a hospital anticoagulant clinic. In: BPC 2009 British Pharmaceutical Conference, 6th - 9th September 2009, Manchester, UK.

Focal Points
The study investigated if general practitioners (GPs) were aware that their patients took warfarin when supplies of the drug were being provided by a hospital anticoagulant clinic.
The clinic checked an electronic GP prescribing record linked to the hospital to confirm that GP practices had made the appropriate entries to register anticoagulant use. Warfarin was missing from the main repeat prescribing screen of the electronic record in 49% of cases. Where GPs do not have to prescribe medication which is instead supplied by a hospital, then there is a risk that they may have an incomplete prescribing record of such therapy.

Introduction and Objectives
Whenever new general practitioner (GP)-led anticoagulant clinics planned opening to take over the care of well-controlled patients who had previously obtained their supply of warfarin from a pharmacy-led hospital anticoagulant clinic, it was found that the lists of patients identified in each GP practice as taking anticoagulants were different to those held by the hospital. GPs were unsure which of their patients took warfarin. A poor communication system when clinical responsibility for anticoagulant therapy is transferred has been identified as an area of
risk. Because the hospital routinely accessed the main locally used electronic GP prescribing program (SystmOne) for confirming medication histories, the hospital pharmacy clinic was asked by primary care to make use of this access to try to identify reasons for the mismatch.

The audit involved accessing GP electronic records either in hospital or at the GP practice after a period of at least 4 weeks following each new patient referral by the hospital to the pharmacy-led clinic. A check was made to confirm that practices had received and registered information sent by the hospital about warfarin in the form of consultant discharge summaries, discharge letters and outpatient clinic letters. The main ‘repeat template’ prescribing field of the electronic record (used to generate repeat prescriptions) was investigated to determine if the practice had highlighted that warfarin was being provided by a third party and that the record relating to anticoagulation was comprehensive. This included checking that the practice was aware of the duration of anticoagulant therapy and in patients taking aspirin, determining if this had stopped or continued to be prescribed.

Results and Discussions
From a sample of 84 referrals by the hospital to the pharmacy clinic, 51 patients belonged to GP practices using SystmOne. From this latter group, there was only one instance where hospital communications had not been scanned onto the electronic record by a GP practice. Nevertheless, in 25 cases (49%), warfarin had not been entered on the repeat template, possibly because the GP was not being asked to prescribe the drug. This meant that as details of warfarin use were consigned to less frequently accessed sections of the electronic record, the GP might easily overlook that anticoagulation had commenced. Information about the duration of warfarin treatment was invariably absent. There were 18 cases where patients had remained on aspirin unintentionally and two instances where the hospital had not indicated if it should stop. Overall, information about warfarin was missing, not readily accessed or incomplete in 82.4% of cases. As there was no hospital electronic link with non-SystmOne practices, it is not clear if a similar picture would be found there.

Where GPs do not have to prescribe warfarin because it is already being provided in hospital, then there is a risk that their practice records about anticoagulation may remain incomplete. Retinoids, certain drugs for metabolic diseases
and oral chemotherapy may also exclusively be supplied by hospitals, and possibly GPs may similarly not always be aware of their use. Anticoagulant clinic pharmacists could themselves correct the GP electronic record, but this was not a solution for those practices with no electronic link to the hospital. Instead a form was introduced for GPs formally to acknowledge that warfarin was recorded on their patient’s
repeat template as being supplied by the hospital.

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