Anticoagulation clinic versus a traditional warfarin management model

A regional anticoagulation program improves safety and outcomes for both children and adults

BACKGROUND

Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program.

AIMS

The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications).

METHODS

Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed.

RESULTS

The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%.

CONCLUSIONS

In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.

Improving anticoagulation in sub-Saharan Africa: What are the challenges and how can we overcome them?

Patients in sub-Saharan Africa generally have poor anticoagulation control. We review the potential reasons for this poor control, as well as the potential solutions. Challenges include the affordability and centralisation of anticoagulation care, problems with access to medicines and international normalised ratio monitoring, the lack of locally validated standardized dosing protocols, and low levels of anticoagulation knowledge among healthcare workers and patients. Increasing numbers of patients will need anticoagulation in the future because of the increasing burden of noncommunicable disease in the region. We propose that locally developed "warfarin care bundles" which address multiple anticoagulation challenges in combination may be the most appropriate solution in this setting currently.

Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol

BACKGROUND

Use of direct oral anticoagulants (DOAC) is rapidly growing for treatment of atrial fibrillation and venous thromboembolism. However, incorrect dosing of these medications is common and puts patients at risk of adverse drug events. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR). As such tools become more common, exploring ways to understand which aspects are effective in specific settings and how to effectively adapt and implement in existing anticoagulation clinics across different health systems is vital.

METHODS

This three-phase project will evaluate a current nation-wide implementation effort of the DOAC Dashboard in the Veterans Health Administration (VHA) using both quantitative and qualitative methods. Informed by this evaluation, the DOAC Dashboard will be implemented in four new health systems using an implementation strategy derived from the VHA experience and interviews with providers in those new health systems. Quantitative evaluation of the VHA and non-VHA implementation will follow the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Qualitative interviews with stakeholders will be analyzed using the Consolidated Framework for Implementation Research and Technology Acceptance Models to identify key determinants of implementation success.

DISCUSSION

This study will (1) evaluate the implementation of an EHR-based population health tool for medication management within a large, nation-wide, highly integrated health system; (2) guide the adoption in a set of four different health systems; and (3) evaluation that multi-center implementation effort. These findings will help to inform future EHR-based implementation efforts in a wide variety of health care settings.

Structure and function of anticoagulation clinics in the United States: an AC forum membership survey

Many anticoagulation clinics have adapted their services to provide care for patients taking direct oral anticoagulants (DOAC) in addition to traditional warfarin management. Anticoagulation clinic scope of service and operations in this transitional environment have not been well described in the literature. A survey was conducted of United States-based Anticoagulation Forum members to inquire about anticoagulation clinic structure, function, and services provided. Survey responses are reported using summary or non-parametric statistics, when appropriate. Unique clinic survey responses were received from 159 anticoagulation clinics. Clinic structure and staffing are highly variable, with approximately half of clinics (52%) providing DOAC-focused care in addition to traditional warfarin-focused care. Of those clinics managing DOAC patients, this accounts for only 10% of their clinic volume. These clinics commonly have a DOAC follow up protocol (75%). Clinics assign a median of 190.5 (interquartile range 50-300) patients per staff full-time-equivalent, with more patients assigned in phone-based care clinics than in face-to-face based care clinics. Most clinics (68.5%) report receiving reimbursement, which occur either through a combination of patient and insurance provider billing (78.2%), insurance reimbursement only (19.5%) or patient reimbursement only (2.3%). There is wide heterogeneity in anticoagulation clinic structure, function, and services provided. Half of all survey-responding anticoagulation clinics provide care for DOAC-treated patients. Understanding how changes in healthcare policy and reimbursement have impacted these clinics remains to be explored.