Ambulatory Care: Anticoagulation Management

American Journal of Pharmaceutical Education, Spring 2002 by DeBisschop, Michael

DENISE KOMOROWSKI-SWIATEK AND MARY T. PASKO. Ambulatory Care: Anticoagulation Management. Bethesda MD: American Society of Health-System Pharmacists, Inc., 2001. xvii 431 pp., 9 figs., 31 tbls., $50.82 (paperback).

This title is the latest workbook in the ASHP Ambulatory Care Clinical Skills Program. Its style is similar to the other entries in this series (including the Core Module, to which it refers often) and readers who have been through those other books will find much that is familiar here. The book presents a very thorough and systematic thought process for anticoagulation management, with plentiful examples and two large, continuing cases on which to practice. While the detailed descriptions of these strategies are aimed at the relative newcomer to ambulatory clinical practice, the book somewhat paradoxically assumes that the reader possesses an advanced level of pathophysiology and therapeutics knowledge. Therefore, this text should be used in conjunction with a comprehensive clinical reference such as the Chest ACCP consensus guidelines; it is best suited to teach anticoagulation management to pharmacy residents, new anticoagulation practitioners, or advanced students.

Like the others in this series, the book is divided into three sections: data collection, assessment, and management. Approximately one-third of the page count of each section is devoted to didactic text; the remaining two-thirds consists of examples illustrating the principles involved, with many charts and forms (with blank copies) to organize patient information and thought processes. In the first section, data collection, the authors do a thorough job of explaining the specific data which are needed for anticoagulation management, and why. The first chapter in the second section discusses assessment of current therapy, and is the most informative chapter in the book. It details everything the pharmacist must think of when assessing anticoagulation therapy and contains many excellent reference tables. The later chapters in this section discuss identifying goals, designing a regimen, and monitoring. These shorter chapters, as well as those in the third section, which deals with management, seem less informative and more repetitive. Although the repetition may be helpful in hammering points home for the beginning clinical pharmacist, the more advanced practitioner will find little of interest in these chapters, which seem to be required in order to conform to the rest of the ASHP Clinical Skills Program series. However, the practice cases in each of these chapters are excellent and illustrate the concepts well.

While this text is very thorough in describing what should be done in managing anticoagulation therapy, it does not go into great detail about how it should be done. The sections on point-of-care testing devices, dealing with other health-care professionals, and adjusting warfarin dosing are short and underdeveloped. The monitoring and documentation forms used are consistent with the rest of the Clinical Skills Program and adequate for teaching, but somewhat impractical for everyday clinic use. Despite a good section on patient education, the lack of a complete, practical patient information handout is glaring. And those seeking practical suggestions on starting an anticoagulation clinic, how to obtain reimbursement, or evidencebased recommendations on anticoagulation therapy will not find them here.

In summary, this workbook provides a solid theoretical background to managing anticoagulation patients and is best used in combination with a separate clinical reference for teaching anticoagulation management to beginning clinical practitioners. Those who have used other modules in the Clinical Skills Program before and found them helpful will be comfortable with this one as well. Although experienced anticoagulation pharmacists may find some good suggestions for organizing or fine-tuning their data collection and assessment skills, the dearth of practical advice will make it less useful for them.

Michael DeBisschop

University of coming