Optimization of DOAC management services in a centralized anticoagulation clinic

Abstract

Background:In 2017, the Brigham and Women's Hospital Anticoagulation Management Service (BWH AMS) expanded services to patients on direct oral anticoagulants (DOACs). We have since updated our DOAC management plan and adjusted the workflow of our clinic. Objectives: This report describes how our DOAC management has evolved and describes key interventions made. Additionally, we report on the results of a survey completed by referring physicians that assessed perspectives regarding centralized DOAC management by BWH AMS pharmacists. Methods: An analysis was completed of all patients referred to the BWH AMS and the number of interventions completed and documented in our anticoagulation management software. A survey with eight questions was sent to 110 referring physicians (selected based on referring to the AMS within the past 1.5 years). Results: Over 4 years, 1622 patients on DOACs were referred to the BWH AMS, amounting to 3154 DOAC encounters. A total of 212 interventions for medication procurement, 171 dose adjustment interventions, and 603 coordinated procedure plans were completed. Of the 32 physicians who responded to the survey, many believed that the quality and safety of anticoagulation therapy was improved with BWH AMS management. Despite provider satisfaction with pharmacist-led care in DOACs, physicians expressed concerns regarding the lack of provider awareness of the clinic and possible duplicative efforts. Conclusion:We plan to evolve the DOAC clinic model to optimize its clinical and operational value and to improve our delivery of care using electronic tools to move toward a population management approach for DOAC management.

Are outpatient anticoagulation management services the wave of the future (again)?

“…However, even in the absence of a need for frequent dose adjustments DOACs remain high‐risk medications and are vulnerable to dosing errors, medication interactions and variability from renal and hepatic function as well as absorption. According to Sylvester et al, 1 rationale for using AMS for DOAC patients include safer and more effective transitions of care and reduced provider burnout. Specific services provided for DOAC patients include dose adjustments, procedure planning, assessment of adherence, assessment for bleeding/recurrent thromboembolism, side effects, new medications/interactions, and periodic laboratory assessment for changes in renal or liver function.…”

“…In their recent paper, Sylvester et al 1 report on their successful experience managing DOACs using an outpatient anticoagulation management service (AMS). The original model for the outpatient AMS was designed to facilitate the frequent monitoring and nuanced dose adjustments necessary to optimize effectiveness and minimize bleeding in patients using VKAs 2 .…”

A call to action for anticoagulation stewardship

“…In another recent study, Sylvester et al 18 describe experiences and outcomes associated with evolving their pharmacist‐run outpatient anticoagulation clinic to provide stewardship over DOACs. Over a 4‐year period, the anticoagulation management service (AMS) completed 3154 DOAC follow‐up encounters in 1622 patients.…”

“…Koolian et al 16 and Sylvester et al 18 are to be commended for publishing their experiences and providing meaningful momentum to advance anticoagulation stewardship. As evidenced by their program descriptions, there is no one‐size‐fits‐all approach, and program setting, size, structure, and scope will be heavily dependent on local resources and organizational needs.…”

Creation of a novel specialty residency in thrombosis and hemostasis management

“…Upon hiring, all new employees complete the ASHP Anticoagulation Certificate Program as well as other hospital-specific training for the clinic. After referral by a physician, a pharmacist will prescribe anticoagulation and required laboratory tests and work closely with the referring doctor under a Collaborative Drug TherapyManagement Agreement (CDTM) 30. Based on state regulations for CDTM, BWH credentials qualified pharmacists as mid-level providers and allows them to prescribe medications (including initiation, modification, or discontinuation) and order related lab tests for the disease state(s) outlined in the collaborative agreement that is signed by both the pharmacist and supervising physician.31 Clinical activities and responsibilities of the pharmacists in these anticoagulation stewardship programs go beyond that of the core residency training and are essential to better anticoagulation care.…”