title: Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya.
abstract: BACKGROUND
  It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease.
  
  
  OBJECTIVE
  To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings.
  
  
  METHODS
  A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon's rank sum analyses were used to establish predictors of TTR.
  
  
  RESULTS
  For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow-up of < 120 days were associated with having a lower TTR (P < 0.05).
  
  
  CONCLUSIONS
  The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya. imranmanji@hotmail.com
authors.forename: I
authors.initials: I
authors.lastname: Manji
authors.forename: S D
authors.initials: SD
authors.lastname: Pastakia
authors.forename: A N
authors.initials: AN
authors.lastname: DO
authors.forename: M N
authors.initials: MN
authors.lastname: Ouma
authors.forename: E
authors.initials: E
authors.lastname: Schellhase
authors.forename: R
authors.initials: R
authors.lastname: Karwa
authors.forename: M L
authors.initials: ML
authors.lastname: Miller
authors.forename: C
authors.initials: C
authors.lastname: Saina
authors.forename: C
authors.initials: C
authors.lastname: Akwanalo
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D016903:Drug Monitoring; D006295:Health Resources / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007630:Kenya; D010595:Pharmacists / Q000191:economics / Q000592:standards*; D012189:Retrospective Studies; D012214:Rheumatic Heart Disease; D012424:Rural Population; D054556:Venous Thromboembolism / Q000188:drug therapy* / Q000453:epidemiology; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin