Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management

Rossier, Connor; Spoutz, Patrick; Schaefer, Monica; Allen, Arthur L.; Patterson, Mark E.

doi:10.1007/s11239-020-02341-y

Cited by 11 publications

(15 citation statements)

References 5 publications

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“…Importantly, incorporation of DOAC eligibility criteria into progressive clinical care models, such as population health dashboards, may represent an important opportunity to promote broader scale, more efficient optimization of high-risk, yet essential, anticoagulant therapies. 36,37…”

Section: Discussionmentioning

confidence: 99%

“…Next steps at our institution include exploring utilization of the DOAC eligibility checklist by outpatient clinics and identification of departments/areas in the hospital where the checklist may be underutilized. Importantly, incorporation of DOAC eligibility criteria into progressive clinical care models, such as population health dashboards, may represent an important opportunity to promote broader scale, more efficient optimization of high‐risk, yet essential, anticoagulant therapies 36,37 …”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

White

Bos

Nawarskas

et al. 2023

J Am Coll Clin Pharm

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Background Over 6 million people in the United States require anticoagulation. Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for select indications due to increased safety and similar efficacy. However, data suggest warfarin to DOAC conversion occurs in less than 5% of patients. Objectives To assess rates of conversion from warfarin to DOACs and the rate of inpatient pharmacist assessment for warfarin to DOAC conversions using an evidence‐based DOAC checklist. Methods In this retrospective cohort study, all patients ≥18 years old admitted on warfarin from January 1, 2018 to February 28, 2020 were identified via query of the electronic health record (EHR). Patients were excluded if discharged to hospice or if anticoagulation was permanently discontinued. In January 2019, an evidence‐based checklist was developed by the inpatient antithrombosis stewardship team and embedded into an EHR‐based standardized clinical documentation form prompting pharmacist assessment for DOAC therapy. Autoregressive integrated moving average (ARIMA) models were utilized to compare pre‐ and post‐implementation rates of pharmacist‐driven evaluation for warfarin to DOAC switch along with actual conversion rates. Additional outcomes were documented reasons for not switching and proportion of newly‐switched patients referred to our antithrombosis clinic. Results Ultimately, 538 inpatient encounters were included (237 pre‐implementation of the DOAC eligibility checklist; 301 post‐implementation). Warfarin to DOAC conversions increased from a mean of 1.08 patients/month pre‐implementation of the DOAC eligibility checklist to 3.62 patients/month post‐implementation (p < 0.0001). Likewise, pharmacist evaluation for switch increased significantly from a mean of 2.00 patients/month pre‐implementation of the DOAC eligibility checklist to 17.69 patients/month post‐implementation (p < 0.0001). In addition, referrals to the anticoagulation clinic significantly increased from a mean of 1.08–4.08 patients/month (p < 0.0001). Conclusion Use of an evidence‐based checklist embedded into the inpatient EHR increased warfarin to DOAC conversions and supported overall antithrombosis stewardship efforts. Conversion rates remained fairly low. Further opportunity exists to optimize patient safety and health systems savings with ongoing stewardship efforts.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

White

Bos

Nawarskas

et al. 2023

J Am Coll Clin Pharm

View full text Add to dashboard Cite

show abstract

“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Dietrich

Davis

Talana³

et al. 2022

J Am Coll Clin Pharm

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Introduction: Direct oral anticoagulants (DOAC) are increasingly utilized for the prevention of thrombotic events. Unlike warfarin they do not require drug-level monitoring making dedicated DOAC monitoring uncommon. The purpose of this study is to describe the interventions made by a DOAC monitoring service over 3 years. Materials and Methods: This was a single-center prospective observational study of patients seen at an outpatient clinic between February 14, 2017 and February 13, 2020. Following referral patients met a pharmacist for a DOAC-specific visit. Patient demographics and clinical interventions were collected for all patients. Continuous quality improvement status was received from the local Institutional Review Board. Results: A total of 153 patients completing 336 visits were included. The median age was 75 years (interquartile range [IQR] 69-81) and 41.2% were male. Apixaban was the most common DOAC (82.4% of visits) and atrial fibrillation (AF) was the most common indication (69.7% of visits). A total of 299 interventions were made over 336 visits with an average of 0.9 interventions per visit; the first visit had an average of 1.1 interventions per visit made. Need for updated laboratory monitoring (101 visits, 30.1% of visits) was the most common intervention. There were 94 interventions related to nonadherence and 24 interventions for incorrect dosing due to renal function, drug-drug interaction, or indication. Conclusions: A DOAC monitoring service frequently made interventions. Routine DOAC monitoring should be considered for all patients. It remains unclear if routine DOAC monitoring reduces the rate of clinical outcomes.

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“…The algorithm used to determine dosing appropriateness has been published previously and remains in use with minimal modification over time. 5 As the Corporate Data Warehouse updates daily, this logic applies to the DOAC population anew each day. These flags allow all patients prescribed a DOAC through VHA to undergo evaluation for clinical issues each day the prescription is active—a goal that is unattainable in a standard practice model with scheduled periodic assessments.…”

Section: Doac Pmt: History and Implementationmentioning

confidence: 99%

“…In the atrial fibrillation subgroup, rates of questionable dosing in the SOC group were nearly double that of the DOAC PMT group (10.4% SOC versus 5.3% PMT, P <0.001). 5 …”

Section: Impact and Success Of The Initiativementioning

confidence: 99%

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

Allen

Lucas

Parra

et al. 2021

JAHA

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Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60‐year standard of care from one‐to‐one provider‐to‐patient anticoagulation monitoring to a population‐based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.

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Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management

Cited by 11 publications

References 5 publications

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

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

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

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