Anticoagulation Management Service Research Articles

The quality of pharmacist-led community warfarin management across 2 provinces in Canada: A cross-sectional observational study.

Guidelines for anticoagulation management services recommend personnel be specially trained in warfarin management and suggest using tools such as decision-support software. To date, there have been no Canadian studies documenting the quality of warfarin management using a similar guideline recommended approach. A cross-sectional, retrospective observational study was conducted to measure the quality of pharmacist-led warfarin management using point-of-care international normalized ratio (INR) testing and decision-support software in various ambulatory settings in Canada. Settings included 4 family health teams in Ontario and 40 community pharmacies across Nova Scotia. Quality was measured using time in therapeutic range (TTR) and was reported in 3 manners: mean TTR, median TTR and time-weighted mean TTR. The primary outcome included 963 patients. The combined mean and median TTR for the 2019 Ontario family health teams and Nova Scotia pharmacies was 74.2% and 77.3% (interquartile range 64%-87.9%), respectively. The time-weighted mean TTR was 76.3%. To the best of our knowledge, the TTR achieved by this model of care is the highest reported in Canadian general practice. Since Thrombosis Canada defines good-quality warfarin management as a TTR of 60% or greater, and many studies have reported an association between higher TTR values and lower rates of thrombosis and hemorrhage, this model of care may have significant benefits for patients. This study demonstrates the high quality of anticoagulation management provided by specially trained pharmacists using point-of-care INR testing and decision-support software. These results support expanded access to this service for all Canadians. Can Pharm J (Ott) 2024;157:xx-xx.

Primary Care Clinicians' Prescribing Patterns of Reduced-Dose Direct Oral Anticoagulants for Extended-Phase Venous Thromboembolism Treatment.

The direct anticoagulants (DOACs), apixaban and rivaroxaban, are used for extended-phase treatment of venous thromboembolism (VTE) and have labeling for dose reduction for this indication. The objective of this study was to better understand primary care clinician prescribing patterns of apixaban and rivaroxaban for extended-phase anticoagulation. We conducted a 21-question survey targeting members of the American College of Physicians and United States Veterans Administration anticoagulation management services. Survey questions covered prescribing behaviors for dose reduction of apixaban and rivaroxaban for extended VTE treatment, as well as questions related to the respondent's practice setting. We used logistic regression to assess associations between demographics and prescribing behaviors. We used k-means clustering to identify distinct groups of prescribing patterns. Among 227 respondents, most were attending physicians (60%) and one-third (34%) practiced in internal medicine or primary care. Most (59%) indicated they dose-reduced DOACs. Hospitalists (no outpatient care) were least likely to dose-reduce (OR 0.09 [95% CI 0.03-0.22]), as well as early-career clinicians (0.53 [0.30-0.91]). Pharmacists and clinicians who treat over 500 VTE patients annually were most likely to dose reduce (6.4 [2.9-16.3]), (2.9 [1.5-6.0]), respectively. We identified five clusters of dosing behaviors and characterized clinician makeup. Clusters were primarily differentiated by frequency of dose reduction, DOAC preference, and temporary re-escalation of doses. We identified clinician characteristics that are associated with dose-reduction prescribing behaviors; these analyses provide insight into where targeted interventions, such as protocolization and education, would be most beneficial.

Quality of Oral Anticoagulation with Vitamin K Antagonists and Direct Oral Anticoagulants in ‘real-World’ Patients: Lessons from a Five Years Audit Study

Background: Even with the introduction of direct oral anticoagulants (DOACs), anticoagulation clinics (ACs) stand with a key role in monitoring. Indeed, routine evaluation by health care professionals is recommended as it is with vitamin K antagonists (VKA) with adjustments in practices of anticoagulation management services. Quality of oral anticoagulation (QOA) is associated to better clinical outcomes in those patients with indications for such therapy. It is well established that patients receiving VKA therapy, maintenance of an international normalized ratio (INR) in the therapeutic range is essential for treatment efficacy and safety. It has been reported that ACs should aim for a time in therapeutic range (TTR) between 70-80% to optimize benefit and minimize the risk of adverse events. So far, QOA for DOACs is not fully established. Aim: Since few clinical data are available considering the new era of ACs, this study aims to describe actual trends and QOA of an AC at a large academic medical hospital. Methodology: We retrospectively analyzed 23275 appointments of 5 consecutive years (May 2018 to May 2023), corresponding to 930 patients that are regularly followed up at an outpatient AC of a central hospital under anticoagulation for at least 8 weeks. TTR (≥70%) determined by Rosendaal method was used for patients under AVK and for those individuals in DOACs, QOA was considered the presence of therapeutic plasma levels of the drugs after the European Heart Rhythm Association 2021 in, at least, one determination. Patients were divided according to target INR in 3 groups: Group 1 with target INR 2-3, including 809 patients mean age 65±18 years (mean±SD), majority (36.6%) with atrial fibrillation (AF); Group 2 with target INR 2.5-3.5, including 92 patients with mean age 70±11 years, majority (85.9%) with mechanical heart valves; Group 3 with target INR 3-4, including 29 patients with mean age 63±15 years, majority (55.5%) with antiphospholipid syndrome. Seventy patients were under DOACs (apixaban in 74.3%), with mean age of 71±17 years, majority (62.9%) with non-valvular AF, were included in Group 1 and all individuals were under direct inhibitors of factor Xa. Descriptive statistics (mean, standard deviation, minimum, maximum, chi-square), inferential statistics (t-test, A-Nova and effect sizes) tests were performed. Results: The 930 patient population, 52.2% female, mean age of 65±18 years and 87% in Group 1, showed a mortality of 17%. The mean recall interval between appointments was superior to 90 days in 94% of the population. The individuals who died in comparison with the survivors showed higher frequency of AF (54.1%) [ χ 2= 47.099; p<.001; φ=.225], were from Group 1 (93%) [ χ 2= 6.641; p=.036; φ=.085], male (59.2%) [ χ 2= 10.103; p=.001; φ=-.104] and older [76±12 vs .63±18 years (p<.001), respectively]. No differences were noticed in mortality between AVK and DOACs [ χ 2= 1.828; p=.401; φ=-.044], even DOAC patients being older than AVK patients (71±17 vs 65±17; p=.005), respectively. QOA associated with mortality being the individuals who died with higher frequency of no QOA (21.9% vs 13.9%) [ χ 2= 8.126; p=.004; φ=-.101] respectively. The individuals on AVK from Group 1 corresponding to 86% of total population showed a mean TTR of 76%, patients from Group 2 had a TTR of 72% and patients in Group 3 had TTR of 55%. From the individuals under DOACs, only 30% had at least one determination of plasma levels of the drug and all but one showed therapeutic levels. Comparatively with our previous studies related to the periods of 2006-2012 and 2012-2018, we noticed a significant decrease in patient population / appointments size (2087/ 61988) (1587/ 37931),(p <.001) with an increase of TTR in Group 1 (1927/1430 patients) (83% /72%) and Group 2 (120/125 patients) (74% / 69%) but a TTR decrease in Group 3 (40 / 32 patients) (54% / 60%) (p <.001). respectively. Mortality in the 2012- 2018 period was 18%. Conclusions and Discussion: The trends of decreasing the number of anticoagulated patients at our AC with an overall good quality of monitoring but with a low percentage of individuals under DOACs suggests that the majority of anticoagulated population is on these drugs without routine follow up in opposition to the recent recommendations. Our study underlines the importance of the quality of anticoagulation monitoring on mortality that was no different from the previous years before SARS-CoV- 2 pandemic nor between AVK and DOACs.

A qualitative study evaluating provider perceptions of implementing warfarin patient self‐management in the United States healthcare system

AbstractBackgroundDespite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the US healthcare system remains small in comparison to European countries.ObjectivesTo gain understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through exploration of the opinions of select US anticoagulation management service providers.MethodsFocus group discussions were conducted at five geographically diverse sites. Grounded theory analysis was performed on focus group transcriptions using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers to PSM implementation within the US healthcare system.ResultsA total of 29 providers participated in eight focus group sessions. Five major themes emerged from the interviews: (1) “Ideal” PSM candidates possess identifiable characteristics (CFIR domain “Characteristics of Individuals”); (2) Providers harbor fears and lack familiarity with PSM facts and principles (CFIR domains “Characteristics of Individuals”; “Inner Setting”; and “Outer Setting”); (3) Providers mistrust patients' capability to engage in PSM (CFIR domains “Characteristics of Individuals”; “Inner Setting”; “Outer Setting”; and “Process”); (4) Despite acknowledging PSM advantages many providers cite workflow issues as barriers to implementation (CFIR domains “Intervention Characteristics”; “Inner Setting”; “Outer Setting”; and “Process”); and (5) Providers differed on how to best train patients to do PSM (CFIR domains “Intervention Characteristics”; and “Inner Setting”).ConclusionsProvider concern for patient safety contributes to hesitancy to relinquish control and mistrust of patients' ability to participate in PSM. Education and implementation strategies will be key to overcoming barriers to PSM in the United States.

Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation

Anticoagulation management services (AMSs; ie, warfarin clinics) have evolved to include patients treated with direct oral anticoagulants (DOACs), but it is unknown whether DOAC therapy management services improve outcomes for patients with atrial fibrillation (AF). To compare outcomes associated with 3 DOAC care models for preventing adverse anticoagulation-related outcomes among patients with AF. This retrospective cohort study included 44 746 adult patients with a diagnosis of AF who initiated oral anticoagulation (DOAC or warfarin) between August 1, 2016, and December 31, 2019, in 3 Kaiser Permanente (KP) regions. Statistical analysis was conducted from August 2021 through May 2023. Each KP region used an AMS to manage warfarin but used distinct approaches to DOAC care: (1) usual care (UC) by the prescribing clinician, (2) UC plus an automated population management tool (PMT), or (3) pharmacist-managed AMS care. Propensity scores and inverse probability of treatment weights (IPTWs) were estimated. Direct oral anticoagulant care models were first indirectly compared using warfarin as a common comparator within each region and then directly compared across regions. Patients were followed up until the first occurrence of an outcome (composite of thromboembolic stroke, intracranial hemorrhage, other major bleeding, or death), discontinuation of KP membership, or December 31, 2020. Overall, 44 746 patients were included: 6182 in the UC care model (3297 DOAC; 2885 warfarin), 33 625 in the UC plus PMT care model (21 891 DOAC; 11 734 warfarin), and 4939 in the AMS care model (2089 DOAC; 2850 warfarin). Baseline characteristics (mean [SD] age, 73.1 [10.6] years, 56.1% male, 67.2% non-Hispanic White, median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex] score of 3 [IQR, 2-5]) were well balanced after IPTW. Over a median follow-up of 2 years, patients who received the UC plus PMT or AMS care model did not have significantly better outcomes than those who received UC. The incidence rate of the composite outcome was 5.4% per year for DOAC and 9.1% per year for warfarin for those in the UC group, 6.1% per year for DOAC and 10.5% per year for those in the UC plus PMT group, and 5.1% per year for DOAC and 8.0% per year for those in the AMS group. The IPTW-adjusted hazard ratios (HRs) for the composite outcome comparing DOAC vs warfarin were 0.91 (95% CI, 0.79-1.05) in the UC group, 0.85 (95% CI, 0.79-0.90) in the UC plus PMT group, and 0.84 (95% CI, 0.72-0.99) in the AMS group (P = .62 for heterogeneity across care models). When directly comparing patients receiving DOAC, the IPTW-adjusted HR was 1.06 (95% CI, 0.85-1.34) for the UC plus PMT group vs the UC group and 0.85 (95% CI, 0.71-1.02) for the AMS group vs the UC group. This cohort study did not find appreciably better outcomes for patients receiving DOAC who were managed by either a UC plus PMT or AMS care model compared with UC.

Standardizing periprocedural anticoagulation management: a stewardship initiative.

Study data indicates anticoagulant interruption peri-procedurally can increase the risk of anticoagulation-related bleeding and thrombosis. Management of anticoagulated patients during the peri-procedural period poses clinical challenges given the potential for thrombosis and bleeding in this complex, high risk population. As such, there is a need for enhanced emphasis on anticoagulated patient care throughout the peri-procedural period with the goal of optimizing patient safety and efficacy. To operationalize an effective, efficient, comprehensive, and standardized anticoagulation management peri-procedural process housed within the electronic health record (EHR). The IPRO-MAPPP clinical decision support logic was adapted into a nurse-managed protocol to guide anticoagulation therapy use during the elective peri-procedural period at Bassett Medical Center, an Anticoagulation Forum Center of Excellence. A second phase of this initiative endorsed peri-procedural warfarin and bridging management by the Anticoagulation Management Service. Outcomes revealed 30-day hospital or emergency department admissions remained at or below 1% of the surgical patient population, and below the published national standards for both phases of implementation. Further, no emergent anticoagulation reversal agent use was attributed to peri-procedural care during the assessment period. The phased implementation of this Anticoagulation Stewardship initiative in elective peri-procedural anticoagulation management successfully describes the operationalization and demonstration of high-quality care and low provider practice variation from policy. The integration of clinical decision support systems, in consort with effective communication, via the EHR, provides stability, sustainability, and drives high quality care to optimize patient outcomes.

The Impact of Clinical Pharmacy Services on Direct Oral Anticoagulant Medication Selection and Dosing in the Ambulatory Care Setting

Background: Off-label dosing of direct oral anticoagulants (DOACs) is both common and associated with adverse patient outcomes. Evidence describing best practices to support optimal direct oral anticoagulant (DOAC) dosing is limited. Objective: To describe the impact of clinical pharmacist intervention on DOAC prescribing. Methods: This retrospective study was a descriptive analysis conducted within an integrated healthcare system with a centralized, pharmacist-led Anticoagulation Management Service (AMS). Patients prescribed a DOAC between January 1, 2020 and December 31, 2020 were included. Pharmacy dispensing reports were generated for pharmacist review and anticoagulant drug therapy changes were recommended to physicians where appropriate. The primary objective was to describe the number and type of recommendations made. Secondary objectives were to determine the provider acceptance rate based on the intervention type and on clinical vs formulary recommendations. Results: Clinical pharmacists made 147 recommendations for 2331 unique patients included in the analysis. Twenty-three recommendations (16%) were to decrease the dose, 46 (31%) were to increase the dose, 14 (10%) were to change the medication due to clinical scenario, 62 (42%) were to change the medication due to cost, and 2 (1%) were another issue. One hundred twenty-three (84%) recommendations were accepted. The provider acceptance rate was similar for clinical and formulary recommendations (85% and 82% respectively). Conclusion: Implementation of report-driven clinical pharmacist intervention led to an improvement in appropriate DOAC medication selection and dosing.

Real-World Comparison of Direct Oral Anticoagulants to Warfarin Among Patients with Atrial Fibrillation/Flutter Managed By an Anticoagulation Service

Introduction: The use of warfarin to prevent ischemic stroke in patients with atrial fibrillation/flutter (AF) requires routine international normalized ratio monitoring and frequent dose adjustments to optimize time in therapeutic range (TTR). While TTR are generally low in usual care, anticoagulation services are associated with improved TTR and clinical outcomes. The direct oral anticoagulants (DOAC) are preferred to warfarin for AF as randomized controlled trial (RCT) data have shown they are as effective in preventing stroke with a lower risk of bleeding, particularly intracranial hemorrhage, compared to warfarin. However, the mean TTR for warfarin-treated patients enrolled in these RCT were relatively modest (55-65%); thus, it is unclear if clinical outcomes would differ if patients in the RCT control groups had been managed by an anticoagulation service. The purpose of this study was to evaluate the real-world effectiveness and safety of DOAC compared to warfarin among patients with AF followed by an anticoagulation service. Methods: This was a retrospective, longitudinal cohort study conducted at Kaiser Permanente Colorado, an integrated healthcare delivery system with a pharmacist-managed anticoagulation service. Adult patients diagnosed with AF, newly initiated on a DOAC or warfarin, and enrolled in the service between 11/01/2015 and 12/31/2018 were followed until anticoagulant switch/discontinuation, a study outcome, membership termination, or 01/05/2019, whichever came first. The index date was the date of service enrollment. TTR and percent of days covered (PDC, a measure of medication adherence) were calculated for the warfarin and DOAC patients, respectively. The primary outcome was a composite of all-cause mortality, clinically-relevant bleeding, ischemic stroke, or systemic embolism. Secondary outcomes included the individual components of the primary outcome as well as follow-up healthcare utilization. Multivariate Cox proportional hazards (reported as adjusted hazard ratio [aHR] with 95% confidence interval [CI]) and negative binomial (reported as adjusted incidence rate ratio [aIRR] with 95% CI) regression analyses were performed to assess differences between groups. All aspects of this study were reviewed and approved by the KPCO Institutional Review Board before data collection. Results: There were 2928 patients included with 1537 and 1391 warfarin and DOAC patients, respectively. The cohort was primarily older, male, and white with moderate burden of chronic disease and baseline healthcare utilization. Warfarin patients had a mean TTR of 72% and were more likely to be female and Medicaid beneficiaries and have had dementia, depression, and pulmonary disease comorbidities (all p<0.05). DOAC patients had a mean PDC of 83% and were more likely to have had a baseline hospitalization (p<0.05). With adjustment for age, sex, Charlson comorbidity index, race, Medicaid status, baseline healthcare utilization, dementia, depression and pulmonary disease comorbidities, patients on a DOAC had an associated lower risk of the primary composite outcome (aHR 0.75, 95% CI 0.62 - 0.91), any clinically-relevant bleeding (aHR 0.68, 95% CI 0.51 - 0.92), gastrointestinal bleeding (aHR 0.62, 95% CI 0.46 - 0.54), systemic embolism (aHR 0.59, 95% CI 0.36 - 0.95), and follow-up hospitalization (aIRR 0.76, 95% CI 0.65 - 0.89) (Table). DOAC patients had equivalent risks of ischemic stroke, all-cause mortality, intracerebral bleeding, and follow-up emergency department visits (all p>0.05). Conclusions: This retrospective analysis of a large sample of real-world patients with AF managed by an anticoagulation service identified that DOAC use was associated with improved safety compared to warfarin. Despite high-quality warfarin management, use of DOAC was associated with lower risks of clinically-relevant bleeding, systemic embolism, and hospitalization compared to patients receiving warfarin for AF which reinforce the application of RCT findings to health systems with available anticoagulation management services. Future real-world studies should be conducted to confirm our findings with multiple healthcare delivery systems, a larger sample size, and assessments of the individual DOAC versus warfarin to provide further evidence of the effectiveness and safety of DOAC. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Higher OAK (Oral Anticoagulation Knowledge) score at baseline associated with better TTR (Time in Therapeutic Range) in patients taking warfarin.

A lack in patient knowledge of warfarin therapy is associated with poor adherence. This knowledge gap may result in a lower INR Time in Therapeutic Range (TTR). To investigate association between patient anticoagulation knowledge and warfarin control. Michigan Anticoagulation Quality Improvement Initiative (MAQI2) is a Blue Cross Blue Shield of Michigan sponsored consortium of six anticoagulation management services. Patients prescribed warfarin at two MAQI2 sites completed a voluntary Oral Anticoagulation Knowledge (OAK) questionnaire at warfarin initiation and 6-month follow-up. The results of 20 OAK questions and TTRs (excluding 1st month post-initiation) were compared using chi-square tests, t-tests and multivariate analysis adjusting for SAMe-TT2R2 and days on warfarin. Of 1836 surveys distributed at warfarin initiation, 481 (26.2%) patients completed the baseline questionnaire (within 1month post-initiation): mean OAK score: 14.6 ± 3.4. Of those, 147 (30.6%) completed 6-month follow-up surveys (OAK: 12.7 ± 5.8). Patients with TTR ≥ 70% at baseline scored higher on OAK tests than patients with TTR < 70% in unadjusted analyses (15.1 ± 3.2 v. 14.2 ± 3.5, p = 0.003) and adjusted analysis (p = 0.020). There was no unadjusted or adjusted difference in OAK scores at 6-month follow-up between patients with TTR ≥ 70% and TTR < 70%. For patients who completed baseline and follow-up surveys, there was a decrease of 2.4 points in OAK score between baseline and 6-month follow up (p < 0.001). Higher baseline, but not follow-up, OAK score is associated with better warfarin control and average OAK scores decreased between baseline and follow-up. Further studies are needed to determine what type of patient education may improve patient knowledge retention and warfarin control.

Practical considerations and consensus opinion for children’s hospital–based inpatient hemostasis and thrombosis (HAT) consultative services: Communication from the ISTH SSC Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis

Caring for children and adolescents with disorders of hemostasis and thrombosis (HAT) has become more specialized and requires a unique skill set that many providers are not able to obtain in standard pediatric hematology/oncology/bone marrow transplant fellowship training programs. The influx of numerous therapeutic advances and increasing medical complexity has expanded the need for experienced HAT providers and subspecialty collaboration in the inpatient setting due to the nuances in the management of patients with HAT complications and concerns. While there are data highlighting the benefits of an inpatient hemostasis, thrombosis, and anticoagulation management service in adult hospitals, there are limited pediatric data supporting such programs. In this article, we summarize the current practices of various pediatric institutions in the inpatient management of HAT patients and provide a consensus opinion for the development of a pediatric inpatient HAT service at tertiary care referral centers.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Feasibility study of the Fearon Algorithm in anticoagulation service guided warfarin management

BackgroundPatients receiving warfarin who spend a lower proportion of time in therapeutic international normalized ratio (INR) range (TTR) have a higher risk of both bleeding complications and thromboembolic events. Using warfarin dosing algorithms is one intervention associated with improved INR stability. ObjectiveTo determine the feasibility of an individualized warfarin dosing algorithm (Fearon Algorithm) under anticoagulation management service (AMS) care and compare measures of INR control using the algorithm with standard care. MethodsA pre/post intervention feasibility study consisting of the 12 months prior to patient enrollment (pre-study phase) and 6 months in which patients used the Fearon Algorithm under the supervision of an AMS pharmacist (AMS phase). The primary study outcome was the change in individual TTR. ResultsA total of 30 patients were enrolled in the study, 26 (87%) of whom successfully completed the AMS study phase using the Fearon Algorithm. Median corrected individual TTR increased significantly from 53% (IQR: 39%, 64%) during the year prior to enrollment to 63% (IQR: 57%, 73%) during the AMS phase (p < 0.01) The uncorrected TTR also increased significantly from 52% (IQR: 39%, 64%) to 61% (IQR: 57%, 72%) (p < 0.01). The Fearon Algorithm specified a smaller warfarin tablet strength in half the patients. ConclusionThe Fearon Algorithm is feasible for an AMS to implement in patients receiving long-term warfarin therapy and appears to improve TTR.

Challenges of Anticoagulation Management Service and Need of Establishing Pharmacist-Led Anticoagulation Clinic in Tertiary Care Teaching Hospital, Ethiopia: A Qualitative Study.

PuposeTo explore the challenges of anticoagulation management (AMS) and assess the need for establishing a pharmacist-led anticoagulation clinic (PLAC) at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia.MethodsWe conducted a qualitative study at TASH. Using a semistructured interview guide, we interviewed 15 physicians from different specialties, heads of pharmacy and laboratory departments. We also included 20 patients to explore their general perceptions, and experiences with and challenges of AMS; and the need to implement PLAC in the hospital.ResultsOnly three physicians responded that they had protocols for initiating and maintaining warfarin dosing. Having protocols for venous thromboembolism (VTE) risk assessment, VTE prophylaxis and treatment, bleeding risk assessment, and contraindication to anticoagulant therapy were reported by seven, six, four, and three participants, respectively. Lack of trained healthcare professionals and a separate AMS clinic, inconsistency in INR testing and anticoagulant availability, and longer appointment times were the biggest challenges of the existing AMS, according to 80% of respondents. Fourteen patient respondents indicated that their satisfaction with the AMS was affected by long wait times and inconsistent availability of anticoagulants and INR testing. The head of the laboratory stated that the facilities for INR testing are inadequate and affect the quality of AMS and customer satisfaction, and supplemented by the head of the pharmacy by adding irregularities of supplies and inadequate counseling on anticoagulants. Respondents suggested that there is a need to establish a PLAC with well-adopted standard operating procedures, qualified manpower, adequate training of assigned staff, and sustained supply of anticoagulants and INR testing.ConclusionThe hospital’s AMS is not optimal to provide adequate services during the study period. Based on these findings and recommendations, the supporting literature, and the experiences of other facilities, the PLAC was established in TASH.

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

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

Optimization of DOAC management services in a centralized anticoagulation clinic

BackgroundIn 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. ObjectivesThis 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. MethodsAn 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). ResultsOver 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. ConclusionWe 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.

A national survey of pharmacists and interns in Aotearoa New Zealand: provision and views of extended services in community pharmacies

BackgroundChanges in pharmacy models of care, services and funding have been occurring internationally, moving away from the traditional dispensing role to more extended patient-facing roles utilising pharmacists’ clinical skills. This study aimed to identify the extended services offered by community pharmacy in Aotearoa New Zealand and the barriers and facilitators to extended services provision. The study is unique in that it includes intern (pre-registration) pharmacists.MethodsAn online survey, conducted in 2018, of all pharmacists and intern (pre-registration) pharmacists working in a community pharmacy. Data were analysed using descriptive statistics and regression analyses.ResultsThe results are based on replies from 553 community pharmacists and 59 intern pharmacists (response rate: 19 and 26% respectively). Both pharmacists (83%) and interns (85%) want to work at the top of their scope of practice. Wide variation exists in the specific services individual pharmacists offer. Most pharmacists were accredited to supply the emergency contraceptive pill (95%), sildenafil for erectile dysfunction (86%) and trimethoprim for uncomplicated urinary tract infection (85%). Fewer were able to immunise (34%) or to supply selected oral contraceptives (44%). Just under a quarter could provide a Medicines Use Review (MUR) or Community Pharmacy Anticoagulation Management Service (CPAMS). Of the pharmacists not already accredited, 85% intended to gain accreditation to supply selected oral contraceptives, 40% to become vaccinators, 37% to offer CPAMS and 30% MUR. Interns expressed strong interest in becoming accredited for all extended services.Poisson regression analyses showed key factors supporting the likelihood of providing extended services were owner and management support and appropriate space and equipment. Being excited about the opportunities in community pharmacy, having employer funding and time for training and sufficient support staff were also statistically significant.ConclusionsPharmacists need time and a supportive management structure to enable them to deliver extended services. Health policy with a greater strategic emphasis on funding services and pharmacist training, and developing technician support roles, will help to minimise or eliminate some of the barriers to role expansion both in Aotearoa New Zealand and internationally.

Pharmacist monitoring of direct oral anticoagulants for American Indians and Alaska Natives in the outpatient setting

BackgroundDirect oral anticoagulants (DOACs) call into question the role of traditional pharmacist-run clinics, and few studies have described the incorporation of DOAC’s into traditional anticoagulation management services (AMS) ObjectiveTo describe the incorporation of DOACs into a pharmacist-run AMS for American Indian and Alaska Native (AI/AN) patients and determine outcomes related to adherence, follow-up, and pharmacist interventions. Practice descriptionTraditional AMS embedded in ambulatory clinic. Warfarin managed by pharmacists under a collaborative practice agreement with supervising physician. Practice innovationDOACs incorporated into AMS by transitioning warfarin patients to rivaroxaban and apixaban and managing new patients with DOAC. Follow-up occurred via phone call and at longer intervals. Evaluation methodsSingle-center, retrospective, observational analysis of AI/AN patients who were followed up by pharmacy AMS. The outcomes measured include adherence to DOAC therapy, number of telephonic encounters versus face-to-face visits, frequency of follow-up, types of interventions made at each visit, and an estimate of face-to-face clinic time savings. ResultsA total of 50 patients were included for analysis. The average medication possession ratio was 91%. The majority of visits occurred over the phone (59%), and most follow-up visits occurred every 3 months (62%). The top 3 most frequent interventions were adherence education, initial DOAC education, and education on use of nonsteroidal anti-inflammatory drugs. Practice implicationsTraditional AMS can evolve by incorporating DOACs and maintaining follow-up. ConclusionPharmacist monitoring of DOACs may promote high levels of adherence and lead to time savings by reducing the amount of time spent in traditional AMS.

A Qualitative Systematic Review of Facilitators of and Barriers to Community Pharmacists-Led Anticoagulation Management Service.

Objective:To identify the facilitators of and barriers to the implementation of Community Pharmacists–Led Anticoagulation Management Services (CPAMS).Data Sources:MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL Register of Controlled Trials were searched from inception until August 20, 2021.Study Selection and Data Extraction:All abstracts proceeded to full-text review, which was completed by 2 reviewers. Data extraction was completed by a single reviewer and verified. Analysis was completed using best-fit framework synthesis.Data Synthesis:A total of 17 articles reporting on CPAMS from 6 jurisdictions were included: 2 Canadian provincial programs (Nova Scotia, Alberta), a national program (New Zealand), and 3 cities in the United Kingdom (Whittington and Brighton and Hove) and Australia (Sydney). Facilitators of CPAMS included convenience for patients, accessibility for patients, professional satisfaction for pharmacists, increased efficiency in anticoagulation management, improved outcomes, enhanced collaboration, and scalability. Barriers included perceived poor quality of care by patients, resistance by general practitioners, organizational limits, capping of the number of eligible patients, and cost.Relevance to Patient Care and Clinical Practice:The barriers and facilitators identified in this review will inform health policy makers on the implementation and improvement of CPAMS for patients and health care practitioners.Conclusion and Relevance:CPAMS has been implemented in 6 jurisdictions across 4 countries, with reported benefits and challenges. The programs were structurally similar in most jurisdictions, with minor variations in implementation. New anticoagulation management programs should consider adapting existing frameworks to local needs.

Impact of Systems-Based Hematologists in Maintaining a HIT Program Using Continuous Clinical Audit and Education in an Academic Medical Center

Systems-based hematologists (SBH) play a vital role in navigating the health care system in the use of diagnostic tests that crosses multiple disciplines by implementing evidence-based strategies to improve patient safety and outcomes. In 2013, we demonstrated that an Anticoagulation and Bleeding Management Service (ABS) led by SBH played a major role in developing safe and cost-effective approaches for the diagnosis of patients with heparin-induced thrombocytopenia (HIT) via implementation of a centralized hospital-wide physician paper order protocol (Vaughn et al. Blood. Vol. 124, Abstract 4848). Platelet factor 4 (PF4) ELISA testing decreased from 600 in 2011 to 375 in 2013 (37.5% decrease), and serotonin release assay (SRA) testing decreased from 202 in 2011 to 29 in 2013 (85% decrease). In addition, 100% of patients with positive PF4 ELISA received an automatic consult by the ABS team to determine management of patients with suspected HIT. This led to a reduction in the use of direct thrombin inhibitors (DTI) by 78%. Despite this initial success, we were unsure if these improvements were sustainable moving forward.The purpose of this study was to provide quantitative data demonstrating the continuous impact that SBH have on health care delivery via annual re-auditing on PF4 ELISA testing to identify shortfalls and implement improvements as needed. In 2014, our institution switched to a new electronic medical record (EMR) system using EPIC in the inpatient environment. The 4T's Scoring Calculator physician paper order became obsolete. An electronic order set for PF4 ELISA test was in discussion but due to the complexity of switching to a new EMR system, this discussion was stalled. Now, physicians could order a PF4 ELISA test electronically without a 4T score. As a result, PF4 ELISA testing increased to 402 in 2014 and 632 in 2015. Ordering of SRA test, which was restricted to the ABS team, remained constant at 31 in 2014 and 36 in 2015.To overcome this, throughout 2015-2016, the ABS team gave specific feedback to the ordering physician when a false-positive PF4 ELISA test was ordered inappropriately. This allowed for individual discussion on each patient case to improve physicians' understanding and awareness of HIT testing and management. In addition, departmental-wide lectures on HIT/4T score to attending physicians and residents/fellows were scheduled.Despite these departmental-wide lectures, the ABS team found that ordering physicians remained unclear about calculation of the 4T score. Ordering physicians were calculating higher 4T scores and ordering PF4 ELISA based on their calculations. As a result, specific interactive lectures based on real-life case scenarios where the audience (internal medicine residents) calculated the 4T score for each scenario were given. This allowed for case-based discussions and opportunity for clarifying any uncertainty on the 4T score. Feedback from the residents was overwhelmingly positive. These efforts led to a reduction in PF4 ELISA test by 49% to 323 in 2016. A re-audit revealed that the number of PF4 ELISA test remained steady at 321 in 2017, which demonstrates the success of our interventions (Figure 1).In conclusion, this study highlights the important of re-auditing to maintain the improvements made. Despite initial success, annual re-auditing allowed for early detection of challenges, which then allowed appropriate early intervention. Administrative and financial support from the health care system for SBH allowed for the initiation, implementation and monitoring of this HIT program, and should be encouraged nationwide as a rewarding career opportunity for hematologists interested in hospital quality improvement and patient safety. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Drive-up INR testing and phone-based consultations service during COVID-19 pandemic in a pharmacist-lead anticoagulation clinic in Qatar: Monitoring, clinical, resource utilization, and patient- oriented outcomes.

BackgroundCoronavirus disease 2019 (COVID‐19) pandemic has resulted in unprecedented pressure on healthcare systems and led to widespread utilization of telemedicine or telehealth services. Combined with teleclinics, using drive‐up fingerstick International normalized ratio (INR) testing was recommended to decrease exposure risk of anticoagulation patients.ObjectiveTo evaluate the impact of transitioning from clinic‐based anticoagulation management services to drive‐up and phone‐based services during COVID‐19 pandemic in Qatar.MethodsThe study comprised of two components: a retrospective cohort study of all eligible patients who attended anticoagulation clinic over 1‐year period (6 months before and 6 months after service transition) and a cross‐sectional survey of eligible patients who agreed to provide data about their satisfaction with the new service. Monitoring parameters, clinical outcomes, and resource utilization related to warfarin therapy were compared before and after service transition. Patients' experience was explored through a structured survey.ResultsThere was no statistically significant difference between clinic‐based and phone‐based anticoagulation services in mean time and number of visits within therapeutic range (P = .67; P = .06 respectively); mean number of extreme subtherapeutic and supratherapeutic INR values (P = .32 and P = .34, respectively); incidence of thromboembolic complications and warfarin related hospitalization. There was one reported bleeding and one emergency visit (0.9%) in the phone‐based group vs none in the clinic‐based group. Frequency of INR testing and compliance to attending clinics appointments declined significantly (P = .002; P = .001, respectively). Overall, patients were highly satisfied with the new service. The majority of patients found it better (51.6%) or just as good as the traditional service (44.5%). Patients who preferred the new service were significantly younger than their counterparts (P = .005).ConclusionThe service of drive‐up INR testing and phone‐based consultations was shown to be comparable to traditional anticoagulation service, a finding that supports maintaining such services as part of the new normal after the pandemic is over.