1
|
Samuel P, Cassidy K, Lazarevskiy P, Cope R. Changes in Time in Therapeutic Range Within a Warfarin Anticoagulation Clinic Following Introduction of Direct Oral Anticoagulants. J Pharm Pract 2024:8971900241256779. [PMID: 38797753 DOI: 10.1177/08971900241256779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background: As direct oral anticoagulants (DOACs) have become widely recommended as first-line anticoagulation therapy, patients who remain on warfarin are likely those unable to afford, adhere to, or utilize DOAC therapy due to the presence of a contraindication. It is currently unknown how availability of DOACs have affected populations being managed at warfarin (VKA) anticoagulation clinics. Methods: This was a retrospective chart review assessing warfarin-treated patients at an outpatient anticoagulation clinic. The primary endpoint was the 6-month time in therapeutic range (TTR) before and after DOACs were recommended as first-line therapy by clinical guidelines. Study periods were January to June 2015, before DOACs were recommended over VKA, and January to June 2022, when DOACs were often recommended over VKA. TTR, demographic changes, and the presence of contraindications to DOAC therapy in the clinic population between the two time periods were assessed. Results: No difference in 6-month TTR was observed between study periods (59% in 2015 vs 63% in 2022; P = .45). Patient demographics did not significantly vary, which may be due to the clinic retaining 45% of patients between both time periods. Contraindications to DOAC therapy were identified in 39% of the 2015 group and 49% of the 2022 group (P = .18). The most common contraindication was indication for anticoagulation. Conclusion: Availability of DOACs did not seem to significantly affect the population or management of warfarin-treated patients at an outpatient anticoagulation clinic, however, contraindications and potential challenges to use of DOAC therapy are present in many patients.
Collapse
Affiliation(s)
- Preethi Samuel
- Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Kaitlyn Cassidy
- Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Pauletta Lazarevskiy
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA
| | - Rebecca Cope
- Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA
| |
Collapse
|
2
|
Ha N, Mouland E, Renner E, Sutter-Long D, Bici A, Lanham M, Barnes GD. Assessment of Population-Based Approach to Direct Oral Anticoagulant Management. J Pharm Technol 2024; 40:72-77. [PMID: 38525096 PMCID: PMC10959082 DOI: 10.1177/87551225231226431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Background: As preferences for oral anticoagulation shift from warfarin to direct oral anticoagulants (DOACs), a new care management model is needed. A population approach leveraging a DOAC Dashboard was implemented to track all patients on a DOAC followed by a physician at an academic medical center. The DOAC Dashboard is a real-time report within the electronic health record (EHR) that identifies patients who require evaluation for DOAC dose/therapy adjustment due to changing renal function, age, weight, indication, and/or significant drug-drug interaction (DDI). Objective: This study aims to describe the initial phase of DOAC Dashboard implementation, to evaluate the effectiveness of interventions, and to assess a multidisciplinary approach to management. Method: Retrospective descriptive study of the DOAC Dashboard from August 22, 2019, to January 20, 2022. Primary outcomes include total number of alerts addressed and interventions needed. Secondary outcome is the proportion of interventions implemented by the prescribing clinician. Result: A total of 10 912 patients were identified by the DOAC Dashboard at baseline. A total of 5038 alerts were identified, with 668 critical alerts, 3337 possible critical alerts, and 1033 other alerts. Pharmacists addressed 1796 alerts during the study period (762 critical alerts and 1034 possible critical). Critical alerts included 62 significant DDI, 379 inappropriate dosing, and 321 others. Of the critical alerts, intervention was needed in 291 cases (38%), with 255 (88%) of proposed interventions implemented. Critical alerts and possible critical alerts not requiring intervention were resolved by data entry. Conclusion: The DOAC Dashboard provides an efficient method of identifying patients on DOACs that require dose adjustments or therapeutic modifications.
Collapse
Affiliation(s)
- Nghi Ha
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI, USA
| | - Erin Mouland
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI, USA
| | - Elizabeth Renner
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI, USA
| | - Denise Sutter-Long
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI, USA
| | - Anisa Bici
- Pharmacy Innovations & Partnerships, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael Lanham
- University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Geoffrey D. Barnes
- University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| |
Collapse
|
3
|
Doolin JW, Schaffer AC, Tishler RB, Jacobson JO. An analysis of medical malpractice claims against medical oncologists from a national database: Implications for safer practice. J Healthc Risk Manag 2024; 43:18-28. [PMID: 38098175 DOI: 10.1002/jhrm.21563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/27/2023] [Indexed: 12/24/2023]
Abstract
Malpractice claims data include valuable information about patient safety. We used mixed methods to analyze claims against medical oncologists (MO) from 2008 to 2019 using a national database. MO claims were compared to a group of other internal medicine subspecialties (OIMS). Logistic regression was used to examine correlates of closing with an indemnity payment. A subset of claims against MO were thematically analyzed using a validated safety incident taxonomy as a framework. 456 claims against MO were compared with 5771 claims against OIMS. MO claims closed with indemnity payments 29.8% of the time versus OIMS 30.3% (p = 0.87). Median MO and OIMS indemnity payments were similar ($190,591 vs. $233,432; p = 0.20). Correlates of MO claims closing with payment included patient assessment, communication among providers, and safety and security as contributing factors. Thematic analysis identified provider cognitive error, adverse drug events and relational problems as the most common safety incidents. MO malpractice claims have similar outcomes to OIMS. We demonstrate the proof-of-concept of applying a safety incident taxonomy to medical malpractice. Finding ways to reduce patient exposure to provider cognitive errors, adverse drug reactions, and communication breakdowns should be strategic priorities for safer cancer care.
Collapse
Affiliation(s)
- Jim W Doolin
- Lahey Hospital and Medical Center, Hematology/Oncology, Burlington, USA
| | - Adam C Schaffer
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Brigham and Women's Hospital, Internal Medicine, Boston, USA
| | - Roy B Tishler
- Dana-Farber Cancer Institute, Radiation Oncology, Boston, USA
| | | |
Collapse
|
4
|
Geller AI, Shehab N, Lovegrove MC, Weidle NJ, Budnitz DS. Bleeding related to oral anticoagulants: Trends in US emergency department visits, 2016-2020. Thromb Res 2023; 225:110-115. [PMID: 37062120 PMCID: PMC10870325 DOI: 10.1016/j.thromres.2023.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Clinical trials suggest lower rates of major bleeding with direct-acting oral anticoagulants (DOACs) than with warfarin, but anticoagulant-related bleeding remains one of the most common outpatient adverse drug events. METHODS We estimated the number of emergency department (ED) visits and subsequent hospitalizations for oral anticoagulant-related bleeding in 2016-2020 based on active surveillance in a nationally representative, size-stratified probability sample of 60 U.S. hospitals. We estimated rates of ED visits using a nationally-projected retail prescription dispensing database. RESULTS Based on 19,557 cases, oral anticoagulant-related bleeding resulted in an estimated 1,270,259 (95 % Confidence Interval [CI], 644,686-1,895,832) ED visits for the five years 2016-2020, of which 47.8 % (95 % CI, 40.6 %-55.0 %) resulted in hospitalization. Oral anticoagulant-related bleeding resulted in an estimated 230,163 (95% CI, 109,598-350,728) ED visits in 2016 and 301,433 (95% CI, 138,363-464,503) in 2020. During 2016-2020, ED visits for DOAC-related bleeding increased by an average of 27.9 % (95 % CI, 24.0 %-32.0 %; p < .001) per year, while ED visits for warfarin-related bleeding decreased by an average of 8.8 % (95 % CI, -10.7 % to -7.0 %; p = .001) per year. The estimated rate of bleeding visits per 100 patients dispensed oral anticoagulants at least once in 2016-2020 was highest for patients aged ≥ 80 years (13.1; 95 % CI, 6.2-20.0) and lowest for those aged <45 years (4.0; 95 % CI, 2.6-5.5); it was 5.9 visits per 100 patients dispensed DOACs [95 % CI, 2.5-9.2] and 13.0 visits per 100 patients dispensed warfarin [95 % CI, 7.4-18.7]. CONCLUSIONS Although the rates of ED visits for anticoagulant-related bleeding may be lower for DOACs than for warfarin, persistently large numbers of patients requiring ED visits for anticoagulant-related bleeding despite increased use of DOACs and declining use of warfarin suggest that efforts to improve appropriate prescribing and monitoring of anticoagulants remain important.
Collapse
Affiliation(s)
- Andrew I Geller
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA; Lantana Consulting Group, Atlanta, GA, USA
| | - Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Nina J Weidle
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA; Eagle Global Scientific, LLC, Atlanta, GA, USA
| | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| |
Collapse
|
5
|
Porres-Aguilar M, Ansell J, Mukherjee D, Cota-Rangel X, Martínez-Zubieta R, Carrillo-Esper R, Burnett AE. Impact of Hospital-based Multidisciplinary Anticoagulation Stewardship Programs. Arch Med Res 2023; 54:1-6. [PMID: 36481128 DOI: 10.1016/j.arcmed.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
Antithrombotic therapies, especially anticoagulants, are high-risk medications with increased potential for adverse events. The development and implementation of a well-functioning, designated, multidisciplinary anticoagulation stewardship program (MASP), tailored to each hospital-center's needs, has the primary objectives of improving patient-centered outcomes, minimizing undesirable anticoagulation-related adverse events and minimizing hospital length of stay (LOS) and other patient-related costs. Such stewardship programs are pivotal in supporting busy clinicians with consultation on challenging clinical case scenarios, ensuring appropriate use of valuable healthcare resources, achieving compliance with anticoagulant-associated accreditation standards, and positively impacting patient-specific morbidity/mortality outcomes. Herein, we review and discuss the critical need for antithrombosis stewardship and the benefit of formalized MASP in optimizing use of antithrombotic therapies.
Collapse
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA; Sociedad Mexicana de Trombosis y Hemostasia, Ciudad de México, México.
| | - Jack Ansell
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Anticoagulation Forum, Newton, Massachusetts, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Xóchitl Cota-Rangel
- Sociedad Mexicana de Trombosis y Hemostasia, Ciudad de México, México; Departamento de Hematología, Hospital Medica Avanzada Contigo, Aguascalientes, México
| | - Ricardo Martínez-Zubieta
- Sociedad Mexicana de Trombosis y Hemostasia, Ciudad de México, México; Direción Medica, Hospital Español de México, Ciudad de México, México
| | - Raúl Carrillo-Esper
- Sociedad Mexicana de Trombosis y Hemostasia, Ciudad de México, México; Departamento de Medicina Intensiva y Unidad de Quemados, Instituto Nacional de Rehabilitación Guillermo Ibarra, Ciudad de México, México
| | - Allison E Burnett
- Anticoagulation Forum, Newton, Massachusetts, USA; Inpatient Pharmacy Department, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| |
Collapse
|
6
|
Inglis LN, Triller DM, Burnett AE, Grandoni J, Matta L, Sylvester K, Dager WE, Gulseth MP, Fanikos J. Creation of a novel specialty residency in thrombosis and hemostasis management. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Allison E. Burnett
- Department of Pharmacy Services University of New Mexico Hospital Albuquerque New Mexico USA
| | - Jessica Grandoni
- Department of Pharmacy Services Brigham and Women's Hospital Boston Massachusetts USA
| | - Lina Matta
- Department of Pharmacy Services Brigham and Women's Hospital Boston Massachusetts USA
| | - Katelyn Sylvester
- Department of Pharmacy Services Brigham and Women's Hospital Boston Massachusetts USA
| | - William E. Dager
- Department of Pharmacy Services UC Davis Medical Center Sacramento California USA
| | - Michael P. Gulseth
- Department of Pharmaceutical Services Sanford USD Medical Center Sioux Falls South Dakota USA
| | - John Fanikos
- Department of Pharmacy Services Brigham and Women's Hospital Boston Massachusetts USA
| |
Collapse
|
7
|
Burnett AE, Barnes GD. A call to action for anticoagulation stewardship. Res Pract Thromb Haemost 2022; 6:e12757. [PMID: 35865732 PMCID: PMC9289116 DOI: 10.1002/rth2.12757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Allison E. Burnett
- Health Sciences Center, College of PharmacyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | | |
Collapse
|
8
|
Samuelson Bannow B. Are outpatient anticoagulation management services the wave of the future (again)? Res Pract Thromb Haemost 2022; 6:e12735. [PMID: 35664531 PMCID: PMC9152439 DOI: 10.1002/rth2.12735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
|