The ACC/AHA guideline recommendations are undergoing significant changes, becoming more evidence based and scientifically robust with a tendency to exclude recommendations with insufficient scientific evidence.
Background
Electronic medical record–based interventions such as best practice alerts, or reminders, have been proposed to improve evidence‐based medication prescribing. Formal implementation evaluation including long‐term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications.
Methods
We implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline‐adherent drug management before endoscopy, documentation of a medication management plan, guideline‐adherent rates of bridging for high‐risk patients taking warfarin, and evaluation for sustained use of BPA.
Results
Eighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13‐month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline‐adherent medication management compared to those who were not referred (97.4% vs 91.0%;
P
= .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%;
P
≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period.
Conclusion
Implementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline‐adherent medication management and documented management plan, while streamlining preprocedural medication management.
Introduction:
Mismanagement of antithrombotic medications often leads to cancelled elective procedures. Pharmacist-led anticoagulation management prior to elective procedures is not well studied.
Methods:
We implemented a best practice advisory (BPA) that offered referral to a pharmacist-led medication management service prior to elective outpatient gastrointestinal endoscopies. Eligible patients were taking warfarin, a direct oral anticoagulant, and/or a P2Y12 inhibitor for management of atrial fibrillation (AF), venous thromboembolism (VTE), coronary artery disease (CAD), peripheral arterial disease (PAD), and/or mechanical heart valve. Patients referred to the antithrombotic service were compared to those managed by the ordering provider. Outcomes assessed included documentation of a medication management plan, guideline-appropriateness of drug cessation prior to endoscopy, and guideline-appropriate rates of enoxaparin bridging for high risk warfarin patients.
Results:
Seventy-four percent of patients (448/645) were referred to the antithrombotic service. These patients were more likely to have had VTE (33.0% vs. 18.2%), less likely to have CAD (31.9% vs. 40.9%; p=0.009 for indication category), and more likely to be prescribed warfarin (32.8% vs 20.9%, p<0.001). After adjusting for baseline differences, patients referred to the antithrombotic service were more likely to have had pre-procedure medication plan documentation (98.7% vs 56.1%, p <0.001), and pre-procedure antithrombotic management was more likely to follow guidelines (97.5% vs. 91.5%, p=0.024). Guideline-appropriate use of bridging enoxaparin for warfarin patients was not different (10/16 [62.5%] vs. 2/6 [33.3%], p=0.221).
Conclusion:
Pre-procedural antithrombotic medication management by a pharmacist-led team for elective endoscopies was associated with more guideline-adherent management and better documentation of the medication plans.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.