Journal of Pharmacy Practice (JPP)The Comparative Effectiveness and Safety of Ambulatory Care Warfarin Management by Non-physician Providers Versus Usual Medical Care: A Systematic Review and Meta-analysis

This systematic review and meta-analysis of 6 RCTs (n=19,122 citations screened) demonstrates that non-physician providers achieve equivalent time in therapeutic range compared to usual medical care in ambulatory warfarin management, though limited event rates prevent definitive safety conclusions.

⚕️ Key Clinical Considerations ⚕️

• Equivalent TTR outcomes: NPP management showed no significant difference in time in therapeutic range (MD 1.64%; 95% CI -1.86 to 5.16, I² = 0%) compared to physician-managed care
• Safety profile similarity: No significant differences in thrombotic events (RR 1.23; 95% CI 0.36-4.23), hemorrhage (RR 1.07; 95% CI 0.44-2.63), or mortality rates between groups
• Limited safety data: Low event rates across studies (0-4 events per outcome) insufficient to draw definitive conclusions about comparative clinical safety and effectiveness
• Patient satisfaction trends: Non-significant higher satisfaction with NPP care (SMD 0.56; 95% CI -0.04 to 1.15) despite high heterogeneity (I² = 85%) between studies
• Provider diversity included: Studies encompassed pharmacists (4 studies), nurse practitioners (1), and multidisciplinary teams (1) with autonomous dosing authority

🎯 Clinical Practice Impact 🎯

• Patient Communication: NPP models consistently showed favorable patient satisfaction trends across all studies, suggesting enhanced patient experience and engagement in anticoagulation management.
• Practice Integration: Evidence supports NPP warfarin management as equivalent to physician care for TTR outcomes, enabling practice workflow optimization and expanded access to anticoagulation services.
• Risk Management: While surrogate measures show equivalence, insufficient clinical event data necessitates continued vigilance and outcome monitoring when implementing NPP models.
• Action Items: Consider NPP integration for stable ambulatory warfarin patients, ensure standardized protocols and training, and maintain physician consultation pathways for complex cases.

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