Background The complexity of managing vitamin K antagonist therapy has led to the development in many countries of anticoagulant management services. In Belgium, a previous study in Erasme hospital showed that the implementation of a pharmacist-provided anticoagulation management programme improved patient education and general practitioner (GP) communication. Moreover, initiation of direct oral anticoagulants also requires adequate management to improve patient adherence to treatment.

Purpose To analyse the role of a pharmacist in managing anticoagulation therapy.

Materials and methods This was a prospective cohort study including consecutive inpatients newly started on oral anticoagulants (OAC) in an urban teaching tertiary care hospital from January 2012 to September 2013. Patients were identified by reviewing all OAC prescriptions. A dedicated pharmacist provided structured patient education and a standardised anticoagulant treatment discharge report for the GP. Data were prospectively collected by a pharmacist.

Results During the study period, there were 1502 inpatients with OAC prescriptions and 491 (33%) had recently started OAC. Of these 491 patients, 40 were excluded (OAC stopped, death). Of the 451 patients included, the pharmacist provided structured education for 232 (51%) patients and 248 (55%) standardised discharge reports. The pharmacist did not educate 219 patients for various reasons: discharge before the pharmacist visit (158/219), transfer to other institution (56/219), others (5/219). The pharmacist did not have the information to send 203 discharge reports for various reasons: discharge before the pharmacist’s visit (173/203), weekend discharge (14/203), others (16/203). The pharmacist made 235 interventions on treatment (examples: dose adjustments, drug interactions) and issued 455 recommendations to nurses, physicians and patients.

Conclusions The pharmacist plays an important role in anticoagulation treatment management including structured patient education, a standardised discharge report for the GP, advice to nurses and physicians. However, coordination between the pharmacist and the medical staff could be optimised to reduce the proportion of patients discharged before the pharmacist’s visit.

No conflict of interest.