Pharmacists’ confidence when providing pharmaceutical care on anticoagulants, a multinational survey
Int J Clin Pharm
Pharmacists' confidence when providing pharmaceutical care on anticoagulants, a multinational survey
John Papastergiou 0 1 2 3 4 6 7 8 9 10 11 12
Nadir Kheir 0 1 2 3 4 6 7 8 9 10 11 12
Katerina Ladova 0 1 2 3 4 6 7 8 9 10 11 12
Silas Rydant 0 1 2 3 4 6 7 8 9 10 11 12
Fabio De Rango 0 1 2 3 4 6 7 8 9 10 11 12
Sotiris Antoniou 0 1 2 3 4 6 7 8 9 10 11 12
Reka Viola 0 1 2 3 4 6 7 8 9 10 11 12
Maria Dolores Murillo 0 1 2 3 4 6 7 8 9 10 11 12
Stephane Steurbaut 0 1 2 3 4 6 7 8 9 10 11 12
Filipa Alves da Costa 0 1 2 3 4 6 7 8 9 10 11 12
UCL Partners 0 1 2 3 4 6 7 8 9 10 11 12
London 0 1 2 3 4 6 7 8 9 10 11 12
0 Portuguese Pharmaceutical Society (PPS) , Rua da Sociedade Farmacêutica, 18, 1169-075 Lisboa , Portugal
1 College of Pharmacy, Qatar University , PO Box 2713, Doha , Qatar
2 School of Pharmacy, University of Waterloo , 755 Danforth Avenue, Toronto, ON M4J 1L2 , Canada
3 Centro de Investigação Interdisciplinar Egas Moniz (CiiEM) , Campus Universitário, Quinta da Granja, Monte da Caparica, 2829-551 Caparica , Portugal
4 Leslie Dan Faculty of Pharmacy, University of Toronto , Toronto, ON M4J 1L2 , Canada
5 Filipa Alves da Costa
6 Research Group Clinical Pharmacology& Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel , Laarbeeklaan 101, 1090 Brussels , Belgium
7 Farmacia Fernández Vega C.B., C/Par no 26 Urbanización Club de Golf. Alcalá de Guadaira , Sevilla 41500 , Spain
8 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged , Szikrautca 8, Szeged 6724 , Hungary
9 Barts Health Centre; Barts Health NHS Trust , London , UK
10 Shoppers Drug Mart 1271 , 2501 Third Line, Oakville, ON L6M 5A9 , Canada
11 Pharmaceutical Care Division (Meduca), Royal Pharmacists Association of Antwerp (KAVA) , Lange Leemstraat 187, 2018 Antwerpen , Belgium
12 Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University , Akademika Heyrovskeho 1203, 500 05 Hradec Kralove , Czech Republic
Background Guidelines on the management of orally anticoagulated patients are continuously evolving, leading to an increased need for pharmacists to be fully integrated in care provision. Objective To identify self-reported gaps in confidence among practicing pharmacists in the area of anticoagulation. Setting Pharmacists in different work settings in different countries. Method Cross-sectional international survey from October 2015 till November 2016 among pharmacists working in different settings to assess their level of confidence when delivering anticoagulants as well as to identify possible educational needs regarding this medication class. Validation of the survey was ensured. Results Responses from 4212 pharmacists originating from 18 countries were obtained. Pharmacists' level of confidence was significantly higher (p < 0.001) when advising patients on vitamin K antagonists (VKAs) versus non-vitamin K antagonists (NOACs). In general, hospital pharmacists displayed higher confidence levels compared to community pharmacists when advising patients on anticoagulation (p < 0.001). Two distinct patterns of confidence levels emerged relating to basic and advanced pharmaceutical care. Confidence levels when providing advanced pharmaceutical care were significantly higher for Oceania and lower for South America (p < 0.005). Conclusions Pharmacists felt more confident in supporting patients receiving VKAs compared to the more recently introduced NOACs. With the increasing use of NOACs and the risks pertaining to anticoagulation therapy, it is essential to invest in education for pharmacists to address their knowledge gaps enabling them to confidently support patients receiving oral anticoagulants.
Impact of findings on practice
• Education of pharmacists in anticoagulation is essential
for improved pharmaceutical patient care
• Pharmacists perceive a greater need for education on
more recently marketed anticoagulants
• Pharmacists identify e-learning as the preferred method
of educational content delivery
Venous thromboembolism (VTE) and atrial fibrillation
(AF) are two health conditions that require complex
anticoagulation therapy for management and for prevention of
life-threatening thromboembolic events. It is estimated that
10 million new cases of VTE are diagnosed annually
resulting in over 544,000 deaths per year in Europe and 300,000
deaths per year in the US [
]. As 60% of VTE cases occur
after hospitalization, it is a leading preventable cause of
hospital-related death [
]. Globally, there are 33.5 million
patients afflicted with AF [
]. It has been reported that as
many as 10–27% of patients with AF remain undiagnosed
]. AF can lead to ischemic stroke, and patients with AF are
at a five-fold increased risk of stroke compared to the
general population [
]. Depending on an individual’s CHADS2
score, the estimated risk of stroke ranges from 1.9 to 18.2%
if a patient with AF does not receive anticoagulation [
the US, 1 in 5 of the 700,000 strokes which occur annually
are attributed to AF, and this proportion increases to 1 in 3
in those aged over 80 years [
]. Ultimately, patients with AF
have a two-fold increased risk of mortality compared to the
general population [
Oral anticoagulants are the standard modality for the
treatment of these conditions. Compared to placebo, there
is an 83% decrease in the recurrence of VTE with warfarin
or non-vitamin K oral anticoagulant (NOAC) therapy [
Likewise, warfarin reduces the risk of ischemic stroke by
60% in patients with AF [
]. Comparatively, the NOACs
have been shown to be either non-inferior or superior when
compared to warfarin for stroke prophylaxis in AF [
Although warfarin was the most widely used OAC
globally since its approval in 1954, the use of NOACs has
steadily increased since the availability of dabigatran in
2008. In 2014, NOACs accounted for 15.5% of the global
anticoagulant market whereas warfarin use had declined
to 72% [
]. Furthermore, studies have estimated a
threefold increase in NOAC use between 2013 and 2014 in the
United States (US) for AF [
]. This increase in use is
likely attributed to the demonstrated safety, efficacy, and
convenience of the newer agents, and the lack of
international normalized ratio (INR) monitoring or individualized
dose adjustments [
]. Nonetheless, patients are less
likely to receive frequent follow-up as there is no
standardized routine monitoring performed to assess the
anticoagulation effects of the NOACs [
]. While INR may serve
as an indicator of patient adherence with warfarin, patient
self-reported intake is the predominant adherence
assessment used with NOACs [
]. A recent dabigatran analysis
revealed that a 10% decrease in adherence resulted in a
13% increased stroke risk secondary to AF [
]. As such,
patient monitoring, education, and medication adherence
are of critical importance with these novel agents, given
the difference in methods for assessing it as well as the
consequences of non-adherence due to the NOACs’ shorter
The scope of pharmacy practice continues to evolve
globally, and pharmacists are uniquely positioned to play
a broader role in anticoagulation medication management.
Several studies have documented the positive impact from
pharmacists in monitoring and managing warfarin in the
community setting. These benefits include an increased
percentage of INR measurements within therapeutic range,
increased patient understanding of their medication, and
reduced-rates of anticoagulation-related emergency room
visits and hospitalizations [
]. Given that self-reported
adherence rates with NOACs are as low as 57% [
pharmacists may be able to have a similar impact on patients
receiving NOAC therapy.
The International Pharmacists for Anticoagulation Care
Taskforce (iPACT) is an expert group committed to further
enhance the key role pharmacists play in anticoagulation
management. Whilst pharmacists are well suited to monitor
patients receiving oral anticoagulation, to our knowledge,
an assessment of their knowledge in providing
consultations has not been formally undertaken. Historically, needs
assessment surveys have been successfully used to identify
the self-perceived confidence of pharmacists in emerging
therapeutic fields and to identify professional needs prior to
developing continuing professional education and
development programs [
Aim of the study
The main study purpose was to identify self-reported gaps in
knowledge and confidence among pharmacists in the area of
anticoagulation and to explore preferred educational
methods to close these gaps. An additional objective was to
identify any difference in confidence levels between countries.
This study was centrally approved by the Comissão de Ética
Egas Moniz in Portugal (Process no. 489). In all countries,
pharmacists were free to decline participation. The
principles of ethical research practices were followed, such as
confidentiality, freedom to participate or withdraw at any
stage, and anonymity.
Design and procedure
This study was a cross-sectional international survey
(available as electronic supplementary material) among
pharmacists working in different settings to assess their level of
confidence when delivering anticoagulants as well as to
identify possible educational needs regarding this
medication class. The questionnaire was originally developed and
validated in English, following literature review,
consultation with external experts and input from iPACT members
experienced in survey development. The Decipher software
(version M35; Quest Mindshare, Toronto, Canada) was used
for developing the web-based survey; and data extraction
was programmed on WinCross 14.0. The questionnaire
consisted of three parts. The first part (including 6 items)
collected participants’ demographic information such as years
of work experience, level of education and area of practice.
The second part (including 13 items) explored pharmacists’
confidence levels when advising patients on various aspects
of anticoagulation medication, and was ranked on a 4 point
Likert scale, ranging from “very confident” to “not
confident at all”. The second part of the survey also asked about
information sources sought to support patient counselling.
The last part (including 6 items) gauged the perceived
educational needs of the pharmacists and asked about the
preferred format and tools to deliver this education. The survey
was translated into 19 different languages and distributed
in 22 countries after being piloted. Piloting was performed
by administration to 10 pharmacists per country and to
assess the burden, applicability, and acceptability among
respondents. Subsequently, the first countries where data
collection was undertaken (France and Canada), were used
to validate the survey, which comprised testing
psychometric properties in a sample of respondents. The process was
then replicated in all participating countries. The survey was
distributed electronically using each iPACT country
coordinator’s network. The most common method involved using
the national and/or regional professional pharmacy
associations for dissemination. Since countries joined the project at
different times, the survey was allowed to run from October
2015 until November 2016. In all countries, the national
coordinator was free to decide on the length of data
collection, which depended mainly on the partner associations
involved in disseminating the survey and the time to reach
the minimum number of 50 respondents per country. The
minimum period to achieve this was 1 month and the
maximum 6 months. In all countries, mail alerts were used as a
reminder technique to increase the response rate.
The survey’s construct validity was examined using
factor analysis. Internal consistency and homogeneity were
examined by calculating Cronbach’s alpha. Categorical
data was summarized as frequencies and percentages.
Comparison between groups was performed using the Chi
square test while comparison of continuous variables was
performed using independent sample t test or ANOVA.
Depending on the number of groups under comparison,
Bonferroni post hoc tests were utilized as required. Linear
regression was performed to assess the effects of potential
predictors on pharmacists’ confidence levels (dependent
variable) when advising patients on anticoagulation
medication. Predictors tested (independent variables) included
age, years of experience, educational level, area of practice
and country of origin. Statistical analyses were executed
with a 0.05 significance level using IBM SPSS Statistics
version 23 (IBM Corp., Armonk, NY, USA).
Characterisation of respondents
A total of 4255 responses from 21 countries were
collected. Countries with no responses (Peru) or with a low
response rate (USA, Slovenia and Chile) were
subsequently excluded. As such, 18 countries with a total of
4212 responses were retained in the final analysis (Fig. 1).
The final list of the countries included were
representative of Europe (66.7%), North and South America (5.6
and 11.1%, respectively), Oceania (11.1%), and the Gulf
Council Countries (5.6%).
The majority of respondents were female pharmacists
(n = 3045; 72.3%), mostly middle aged between 30 and
50 years. Experience in pharmacy varied widely, unlike
formal education where only a minority held a PhD. 67.7%
(n = 2852) of respondents worked in a community
pharmacy, while 27.5% (n = 1157) worked in a hospital. Other
areas of employment, including academia, the
pharmaceutical industry, and independent consultancy firms, represented
a much lower proportion of the sample population.
Pharmacists’ level of confidence was significantly higher
when advising patients on vitamin K antagonists (VKAs)
versus NOACs (p < 0.001) (Fig. 2).
Distinct patterns in confidence level were observed
depending on the surveyed items (Fig. 3). There were no
differences in the confidence levels that could be explained
by the age of pharmacists, their experience of pharmacy
practice or additional formal education (p > 0.05) (results
not shown). In general, hospital pharmacists displayed
higher confidence levels compared to community
pharmacists when advising patients on anticoagulation (p < 0.001).
However, country specific differences in confidence levels
associated with area of practice were observed; for instance
in Belgium, community pharmacists performed similarly to
The underlying themes included in the questionnaire
could be clustered into two main categories. The first group
focused on delivering drug and disease-related information
such as drug indications or expected benefits of treatment.
In some countries, this practice is a compulsory part of basic
pharmaceutical care. The second category included
delivering more advanced pharmaceutical care and requiring the
pharmacist to manage more complex issues such as the
identification and treatment of bleeds. This categorization was
confirmed by the rotated factor plotting, clearly visualizing
that the individual items load into the respective components
described (Fig. 4).
The two components shown in Fig. 4, basic
pharmaceutical care and advanced pharmaceutical care, displayed high
internal consistency in the overall sample (α = 0.851 and
α = 0.877, respectively), with insignificant variations at the
country level (ranging from 0.757 to 0.878 for component 1
and from 0.772 to 0.924 for component 2).
Analysis of confidence levels by continent of origin
identified differences between the groups for the two
components (p < 0.001). Post-hoc analysis highlighted that with
regard to confidence levels when providing patients with
basic pharmaceutical care (component 1), only South
American countries performed significantly lower than all others
(p < 0.001). On the other hand, two extremes in confidence
levels were detected when providing patients with advanced
pharmaceutical care (component 2). South American
countries performed significantly lower and Oceania performed
significantly better (p < 0.005) in this regard compared to
all others (Fig. 5).
Linear regression was used to analyse predictors of
pharmacists’ confidence levels. Two independent models were
considered, where component 1 and component 2 were the
dependent variables. Whilst both models were found to
predict very little of the variability (R2 = 0.196 and R2 = 0.233,
respectively), the same variables were found to influence
confidence levels, suggesting that gender, length of
experience, post-graduate education, and area of practice may
indeed partly explain self-confidence. On the other hand,
continent of origin was identified as an additional predictor
but only for component 2 (Table 1).
Gulf Council Countries
Preferred sources of information for pharmacists and educational needs
When dispensing anticoagulants, pharmacists chose
specialized pharmacy software as their preferred source of
switching 6.2 21.9 52.4 19.4
management of interactions 13.5 47.6 34.0 4.8
INR monitoring and making dose recommendation 11.2 25.1 43.8 19.9
management of missed doses 12.8 37.4 43.7 6.2
management of bleeding 9.9 35.4 48.3 6.5
management of adverse drug reaction 13.3 44.9 38.3 3.6
adverse drug reaction 19.5 55.7 23.0 1.8
indication 21.3 57.6 19.2 1.9
benefits 25.7 58.4 14.4 1.6
0 10 20 30 40 50 60 70 80 90 100
Percentage of respondents (%)
Very confident Confident Not so confident Not confident at all
information (n = 2350; 55.8%), followed by the internet
(n = 2186; 51.9%). Less than half of the respondents used
reference books (n = 1790; 42.5%) or published journal
articles (n = 1255; 29.8%).
Fig. 4 Component plot in
The majority of respondents (n = 3871; 91.9%) reported
that they would like to receive additional education to
improve their confidence level. The preferred areas for
further education followed an inverse trend compared to the
expressed confidence levels. The most desired item in this
regard was interactions (n = 2956; 70.2%), followed by
management of bleeding (n = 2871; 68.2%), and management
of switching (n = 2780; 66.0%). Management of bleeding
was among the top areas receiving educational requests,
while learning about the coagulation pathway was the least
requested topic (n = 1322; 31.4%).
The most popular formats of education were
personalized e-learning (n = 2490; 59.1%), interactive websites
(n = 1760; 41.8%) and symposia (n = 1757; 41.7%). The
least preferred formats identified were education from
peers (n = 493; 11.7%), webinars (n = 970; 23.0%) and
workshops (n = 1473; 35.0%). While these results reflect
the overall trend, there were country-specific behaviours,
where for example education from peers was more
popular among Dutch pharmacists and webinars amongst
In addition to education, pharmacists expressed the
need to have a list of frequently asked questions to
support them while counselling patients (n = 4043; 96.0%).
A quick reference guide was proposed as a solution, either
embedded in the pharmacy software (2754; 65.4%), as a
link to a website (n = 2200; 52.2%) or as a specific app
(n = 1797; 42.7%). Non-technological solutions were less
favoured, e.g. the availability of a pocket guide.
To the best of our knowledge, this is the first global study
that reports data from pharmacists on perceived gaps in
confidence and training needs in the area of
anticoagulation therapy. The diverse, transcontinental sample provides
a valuable snapshot of the status of pharmacists with respect
to their preparedness to provide counselling and education
related to these potentially risky treatment modalities.
Non-vitamin K oral anticoagulants have been
introduced into the market relatively recently as an alternative
to warfarin, and our results showed a higher level of
confidence among pharmacists advising patients on VKAs than
on NOACs. This reflects the long experience with VKAs,
which have been the mainstay of treatment globally for a
much longer period. However, the complexity of therapies
associated with VTE and AF requires an advanced level of
practice, regardless of the anticoagulant used. Warfarin is
consistently reported within the top 3 medications
associated with an adverse reaction leading to a hospital
]. Guidelines recommend that healthcare
providers who are managing oral anticoagulation therapy should
incorporate, in a coordinated manner, patient education,
patient tracking and follow-up and good patient
communication regarding the results and dosing decisions [
For patients receiving VKA anticoagulation therapy, careful
INR testing is key to ensuring treatment success, preventing
thromboembolic events, and managing bleeding risks. Such
an advanced level of practice is typically seen in countries
known to have well-developed pharmacy practice standards
and regulations that support those standards. The results
with respect to pharmacist confidence levels with
anticoagulation therapies mirrored this relationship. Respondents from
Ireland, the UK, the Netherlands, Australia, Canada, and
New Zealand expressed higher levels of confidence in
dealing with VKAs and NOACs than respondents from the other
countries. Respondents from South America were
persistently less confident. Experience with NOACs and their use
in routine practice differs between countries; and this may
be influenced by health economics, pricing, and coverage by
different health systems . Higher gross domestic product
(GDP) countries, for example, do tend to have advanced
pharmacy practice in contrast with lower GDP nations [
This most likely explains the reason for the higher
confidence illustrated in our results. Site of practice also has an
association with the level of perceived confidence in
dealing with anticoagulation management. In general, hospital
pharmacists expressed higher confidence than pharmacists
in other localities. This could be attributed to several
factors. For example, the job demands in a hospital setting, the
interprofessional environment in hospital practice, and the
opportunity for professional development in many hospitals
could explain this result. In contrast, community pharmacy
in ‘developing’ countries is still dominated by the more
traditional dispensing practice.
Over 90% of the participants expressed desire for some
sort of continuing education on different aspects of
anticoagulation management. Assessing training needs was an
important objective in this study. While this was an
opportunity for reflection from the perspective of the pharmacist,
it helps in the development of relevant educational programs
tailored to the perceived needs. The results of this study
have also provided us with an insight on what
information is desired, and in what format this information should
be provided. Methods for learning spanned a wide range
of options, with e-learning and interactive websites being
the most popular. All this information should prove
invaluable in developing continuous education materials to close
the knowledge gaps identified by this study. Other studies
using similar (web-based survey) or comparable techniques
(interview, questionnaire) have also identified pharmacists’
knowledge gaps and education needs in domains such as
transplantation, travel health, weight loss and oral health
This study has some limitations, including the inability
to include a larger sample in some relevant countries
represented by iPACT members, like the USA or Chile, leading
us to exclude them in the final analysis. Nonetheless, data
collection is ongoing in these countries and may be used in
the future to shape pharmacists’ education. The inability to
represent African countries and include only Gulf Council
countries (Kuwait, Qatar, Saudi Arabia and the United Arab
Emirates) as representatives of the Asian continent limits
comparisons. However, the similarities in pharmacy
practice, demographics and education of Gulf Council countries
allowed for a valid grouping of these individual countries
]. Within participating countries, selection bias may have
occurred by using an internet survey. However, in Portugal
data was compared against national data of pharmacists’
demographics, and this showed only minor discrepancies
]. The simplified translation process utilized may have led
to some inadequate terminology use, but the high
consistency evidenced led us to discard this possibility.
Pharmacists reported higher confidence in supporting
patients receiving VKAs compared to the more recently
introduced NOACs. Consistently, pharmacists had greatest
confidence in explaining the indication and the benefits of
anticoagulation and lowest confidence in managing bleeding
and switching amongst oral anticoagulants. With the
increasing use of NOACs and the known risks pertaining to
anticoagulation therapy, it is essential to invest in education for
pharmacists to address their knowledge gaps enabling them
to confidently support patients receiving oral anticoagulants.
Acknowledgements The authors would like to acknowledge all the
organisations that have facilitated this survey and helped in its
dissemination: Portuguese Pharmaceutical Society, Royal Pharmacist
Association of Antwerpen (KAVA), Association of Flemish Hospital
Pharmacists (VZA), Belgian Institute for Continuing Education for
Pharmacists (IPSA), Société Française de Pharmacie Clinique and
Syndicat National des Pharmaciens des Établissements Publics de Santé,
Pharmaceutical Society of New Zealand, Pharmaceutical Society of
Australia, Hungarian Chamber of Pharmacists, Sociedad Española de
Farmacia Familiar y Comunitaria, Brazilian Society of Hospital
Pharmacy and Health Services (SBRAFH), Croatian Chamber of
pharmacists and the Croatian Pharmaceutical Society, Czech Chamber of
Pharmacists, Canadian Pharmacist Association, The Royal Pharmaceutical
Society of Great Britain. They are also grateful to the individuals that
made data collection possible: Cassyano Correr (Brazil), Elena María
Veja (Chile), Sonia Uema (Argentina) and Anna Olearova (Slovakia).
In addition, they acknowledge Mr. Ales Antonin Kubena for the
statistical support as well as all project collaborators and members of iPACT.
Funding The project was funded by the Davie-Ratnoff-Macfarlane
Conflicts of interest The DRM foundation received educational and
research support grants from Bayer.
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