Dr Christie Newton’s President’s Message in the February 2023 issue of Canadian Family Physician1 encouraging the adoption of team-based care as one solution to alleviating the current strain on our family physician resources is well timed. Five years ago, I received a request from the Pharmacy Association of Nova Scotia asking for my assistance with the implementation of a Community Pharmacist–led Anticoagulation Management Service (CPAMS) pilot project involving 40 pharmacies in Nova Scotia. The problem facing the province at the time was an acute shortage of family physicians, resulting in a number of patients taking warfarin with no physician managing their care. The proposed solution was to train community pharmacists in CPAMS through a 6-week online course from the University of Waterloo in Ontario, the Management of Oral Anticoagulation Therapy, using point-of-care international normalized ratio (INR) testing devices (CoaguChek XS Pro) and warfarin decision-support software (INR Online) through a government-sponsored 1-year pilot project. Five years later, the project is a wonderful success and strongly supported by family physicians, community pharmacists, nurses and nurse practitioners, and the Nova Scotia government, which has fully funded the program, now available at 95 pharmacies across the province. Many family physicians in Nova Scotia refer their patients to CPAMS because it offloads a cumbersome management issue, provides a more convenient solution for patients, and, most important, greatly enhances the effectiveness and safety of warfarin. The average percentage of time the INR is in therapeutic range (TTR) with CPAMS in Nova Scotia is 75% for patients with atrial fibrillation (2 out of 3 have a TTR >85.7%)2,3 compared with 54% with standard or usual care with warfarin in North America.4 White et al demonstrated that a difference in TTR from below 60% to above 75% resulted in a 49% reduction in the incidence of stroke and systemic embolism, a 55% reduction in myocardial infarction, a 59% reduction in major bleeding, and a 60% reduction in all-cause mortality in patients with atrial fibrillation.5 Direct oral anticoagulants in Canada have failed to reduce the incidence of stroke and systemic embolism and myocardial infarction compared with standard or usual care with warfarin after nearly a decade of use in the real world (Table 1).6

Comparison of adverse events among those receiving warfarin (usual care) and those receiving DOACs

The CPAMS project in Nova Scotia is a great example of a team-based solution with large, measurable improvements in patient care and safety, which could be employed to greatly improve oral anticoagulation management across Canada.

Competing interests

None declared