373 Development of an Acute Deep Venous Thrombosis Clinical Pathway Using Apixaban May Safely Decrease Admission Rates and Improve Access to Care Regardless of Patient Socioeconomic Status

Abstract

Outpatient management for patients presenting to the emergency department (ED) with acute deep venous thrombosis (DVT) has been shown to be safe. However, many patients have neither access to outpatient care nor can afford costly direct oral anticoagulant medications. We developed an ED clinical pathway which aims to improve access issues for all patients presenting with an acute DVT. This is the first such pathway which uses apixaban to these authors' knowledge. Objectives include safely decreasing hospital admissions; reducing downstream readmissions; and increasing outpatient follow-up. We developed an acute DVT clinical pathway. ED providers prescribed apixaban to patients eligible for discharge. ED pharmacists provided medication counseling and free 30-day vouchers. Case managers arranged outpatient appointments and provided financial aid guidance for apixaban treatment beyond 30 days for underinsured patients. For iliofemoral DVTs, interventional radiologists were consulted for consideration of intravascular therapy. ED providers were educated on the clinical pathway December 2016, and it was implemented January 2017. Charts were reviewed from 6 months pre- and post-implementation. Primary outcomes included discharge and outpatient follow-up rates. Secondary outcomes included repeat ED visit and hospitalization rates for DVT-related illness following discharge. Only patients with acute DVT diagnosed on formal Doppler ultrasound were included. Dichotomous variables were compared using the Fisher Exact Test. The following pathway was implemented 53 patients diagnosed with an acute DVT in the ED were reviewed from the 6 months before (n = 23) and after (n = 30) implementation of the pathway. Although no results reached statistical significance, all results were consistent with the hypotheses. After implementation, discharge rates increased from 39.1% (n=9) to 56.7% (n=17), (p=0.271). Discharged patients were more likely to follow up with a provider within 30 days or prior to readmission for DVT-related illness, 64.7% (n=11) versus 44% (n=4), (p=0.419). Post-discharge ED revisits and hospitalizations for a DVT-related illness decreased from 33% (n=3) to 17.6% (n=3), (p=0.628). No deaths were found at 90 days of those discharged from the ED in either group. We created an outpatient clinical pathway for patients diagnosed with acute DVT in the ED using apixaban regardless of socioeconomic status. Initial pilot data demonstrate nonsignificant trends towards decreased hospital admissions and improved follow-up without compromised patient safety. Given these pilot data, more highly powered research is necessary to fully identify the impact this pathway may have on patient outcomes and health care costs.