Evaluation of a multicomponent integrated intervention to improve the quality of care for anticoagulated frail older adults in a home care system in the city of Buenos Aires

Abstract

Introduction: Anticoagulation in older adults is a real challenge due to the presence of health conditions that can alter the adequate control of the patient. Older adults confined to home probably could not attend outpatient medical consultations. On many occasions, the monitoring of the patient's health process at home is carried out by a health professional who does not monitor the anticoagulant treatment (e.g. due to lack of experience of the professional).
 For this reason, the home care section of the Italian Hospital of Buenos Aires (HIBA) created an interdisciplinary team for the telephone follow-up of anticoagulated patients in that area.
 Objectives: Describe the effect of a multicomponent intervention to improve the quality of anticoagulation therapy in frail elderly patients in the home care system of the HIBA.
 Methods: Prospective pragmatic evaluation study of a multiple intervention with a before-after design. Variables were analyzed from secondary databases 6 months before and after the intervention. The unit of analysis was the patient acting as his own control. The setting was the home medicine section of HIBA. We included patients aged 65 years or over receiving dicumarinics with home care and follow-up by a doctor with fewer tools in the management of anticoagulants and with communication barriers. Telephone contacts with patients were made by family physicians. A hematologist was consulted whenever necessary. Pharmacists sent pills of vitamin K with educational brochures to the patient's home. Health and social counsellors contacted patients in complex cases to strengthen education. Reasons for withdrawal of the program were: death, hospitalization, termination of the home care service, follow-up of the treatment by a hematologist or anticoagulant suspension.
 Results: Analysis of the data was performed before the intervention (June 1, 2021 to November 30, 2021) and after the intervention ( December 1, 2021, to June 30, 2022), 41 patients were included, 78% were female, average age was 87 years. The mean of basic activities of daily living was 3.35, the average of the Percentage of International Normalized Ratio Measurements in Range (PINRR) in the pre intervention was 31% and 49% in the post. There weren't thrombotic events and the average of bleeding events was 6% in the pre and 0% in the post, extreme values of INR (>6) in the pre was 3% and in the post 0,5%. Finally the mean of emergency medical consultations was 1,15 in the pre and 0,29 in the post.
 Conclusions: The present work consists in the analysis of an elderly population highly dependent on activities of daily living. The data shows a possible tendency of reduction in the number of emergency medical consultations, bleeding events and improvement in the PINRR. As next steps we propose evaluate patients' satisfaction with the intervention, analize long-term results as the program works in time and generate institutional tools to deprescribe.