Impact of a Direct Oral Anticoagulant Population Management Tool on Anticoagulation Therapy Monitoring in Clinical Practice

Abstract

Background: The optimal monitoring and follow-up strategy for long-term direct oral anticoagulant (DOAC) therapy has not been established. Historically, at our medical center, DOAC patients were referred to a clinical pharmacy specialist managed anticoagulation clinic (AC) for monitoring via regularly scheduled encounters (face-to-face or telephone). Objective: To determine if implementation of a DOAC Population Management Tool (PMT) designed to identify patients who most likely require clinical review and possibly intervention, would improve the efficacy (interventions per patient) and efficiency (time invested to generate an intervention) of monitoring over AC practices. Methods: The DOAC PMT group included patients flagged as potentially having a dosing issue or history of valve replacement. The AC group included patients who were scheduled for routine DOAC follow-up. The quantity and character of interventions made were prospectively recorded and compared. Results: A total of 399 patients were included. Data were collected for 131 patients identified by the DOAC PMT, resulting in a review of 170 flags with a total of 94 interventions or 0.55 interventions per flag reviewed. For the AC group, 268 patients were evaluated, leading to 53 interventions or 0.20 interventions per patient encounter ( P < 0.001 for comparison). The time to generate an intervention was 16 minutes in the DOAC PMT versus 64 minutes for the AC group. Conclusion and Relevance: A population-based approach to DOAC monitoring represents a more effective and efficient strategy to reduce missed opportunities for interventions between follow-up appointments while also increasing clinic access, particularly for patients who require immediate attention.

Three‐year clinical interventions from an outpatient multidisciplinary direct oral anticoagulant monitoring service

“…The need for updated laboratory monitoring was frequently and consistently identified throughout follow‐up. Population‐based management tools have been developed to assist with DOAC monitoring on a broad scale and can be helpful for identifying the need for updated labs or adjusted doses based on renal function or drug‐drug interactions for high risk patients 29‐34 . While these tools can be helpful at a population level, and include markers of adherence such as MPR or PDC in addition to flagging patients on potentially inappropriate doses or needing updated laboratory monitoring, they cannot replace patient‐level evaluations of adherence.…”

Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants

“…As a result of this improved efficiency, the time to generate an intervention (eg, flag review and subsequent intervention if appropriate versus patient visit, assessment and subsequent intervention) was reduced by 75% (16 minutes versus 64 minutes). 6 In a similar project, Chau reported that incorporating the DOAC PMT into their practice model resulted in a tripling in the number of clinical interventions occurring in 86% less time than standard clinic‐based monitoring. 7 In 2017, May et al reported a 41% increase in pharmacy efficiency after a DOAC PMT‐based practice model was implemented, reporting that the model “… allowed the CPS [clinical pharmacy specialists] to target interventions to high‐risk patients and complete interventions by chart review rather than telephone encounter, thus reducing the workload of the CPS.” 8 The same year, Tolley et al reported, “Clinical pharmacists were able to globally manage a large number of patients prescribed DOACs at the Ralph H. Johnson VA Medical Center and make 1142 interventions in 699 patients (56% of the DOAC population) within a 2.5 month time period.” 9…”

Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol

“…This study will help explore the impact of population health tools for safe anticoagulant medication management in a variety of different clinical contexts use, these tools address one critical component (appropriate dosing) in an efficient manner [22]. Such tools are currently being used for population-based management of patients with diabetes [23].…”