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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.
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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
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2
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Triller DM, Wilson AS, Allen AL, Burnett AE, Gouveia-Pisano JA, Brenner A, Pritchard BK, Medico C, Barnes GD. Digital dashboards for direct oral anticoagulant surveillance, intervention and operational efficiency: uptake, obstacles, and opportunities. J Thromb Thrombolysis 2024; 57:107-116. [PMID: 37839023 PMCID: PMC10830621 DOI: 10.1007/s11239-023-02893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/17/2023]
Abstract
Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is unknown. A survey of Anticoagulation Forum's members was conducted to assess access to digital tools available within a dashboard and to describe implementation models. An Expert Forum was subsequently convened to identify barriers to dashboard development and adoption. Responses were received from 340 targeted recipients (8.5% of invitees). Only a minority of inpatient (25/52, 48.1%) and outpatient (47/133, 35.3%) respondents outside of Veterans Health Administration were able to generate rosters of DOAC users on-demand, and fewer had the ability to digitally display key clinical data elements, identify drug-related problems, document interventions, or generate reports. The lack of regulatory requirements regarding Anticoagulation Stewardship was identified by the Expert Forum as the major barrier to widespread development of digital tools for improved anticoagulation management. While some health systems have demonstrated the feasibility of DOAC dashboards and described their impact on quality and efficiency, these tools do not appear to be widely available in the United States apart from Veterans Health Administration. The lack of regulatory requirements for Anticoagulation Stewardship may be the primary barrier to the development of digital resources to better manage anticoagulants. Efforts to secure regulatory requirements for Anticoagulation Stewardship are needed, and evidence of improvements in clinical and financial outcomes through DOAC dashboard use will likely bolster such efforts.
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Affiliation(s)
- Darren M Triller
- Anticoagulation Forum, 17 Lincoln St, Suite 2B, Newton, MA, 02461, USA.
| | - Aaron S Wilson
- University of Utah College of Pharmacy, Salt Lake City, UT, 84112, USA
| | - Arthur L Allen
- Veterans Administration Salt Lake City Health Care System, Salt Lake City, UT, USA
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3
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Wilson AS, Triller DM, Allen A, Burnett A, Gouveia-Pisano JA, Brenner A, Pritchard B, Medico C, Vazquez SR, Witt DM, Barnes GD. Digital dashboards for oral anticoagulation management: a literature scoping review. J Thromb Thrombolysis 2023; 56:568-577. [PMID: 37596426 PMCID: PMC10550856 DOI: 10.1007/s11239-023-02880-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/20/2023]
Abstract
This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting records were systematically evaluated by multiple blinded reviewers and the findings from selected papers were evaluated and summarized. Twelve manuscripts were identified, originating from 5 organizations within the US and 2 from other countries. The majority (75%) described implementation in the outpatient setting. The identified papers described a variety of positive results of dashboard use, including a 24.5% reduction of questionable direct oral anticoagulant dosing in one organization, a 33.3% relative improvement in no-show appointments in an ambulatory care clinic, and a 75% improvement in intervention efficiency. One medical center achieved a 98.4% risk-appropriate venous thromboembolism risk prophylaxis prescribing rate and 40.6% reduction in anticoagulation-related adverse event rates. The manuscripts primarily described retrospective findings from single-center dashboard implementation experiences. Digital dashboards have been successfully implemented to support the anticoagulation of acute and ambulatory patients and available manuscripts suggest a positive impact on care-related processes and relevant patient outcomes. Prospective studies are needed to better characterize the implementation and impact of dashboards for anticoagulation management. Published reports suggest that digital dashboards may improve the quality, safety, and efficiency of anticoagulation management. Additional research is needed to validate these findings and to understand how best to implement these tools.
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Affiliation(s)
- Aaron S Wilson
- University of Utah College of Pharmacy, Salt Lake City, UT, 84112, USA
| | - Darren M Triller
- Anticoagulation Forum, 17 Lincoln St, Suite 2B, Newton, MA, 02461, USA.
| | - Arthur Allen
- VA Salt Lake City Health Care System, Salt Lake City, UT, 84108, USA
| | - Allison Burnett
- University of New Mexico Health Sciences Center, Albuquerque, NM, 87102, USA
| | | | | | | | | | - Sara R Vazquez
- University of Utah College of Pharmacy, Salt Lake City, UT, 84112, USA
| | - Dan M Witt
- University of Utah College of Pharmacy, Salt Lake City, UT, 84112, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, 48109, USA
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4
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Lin YJ, Ranusch A, Seagull FJ, Sussman JB, Barnes GD. Dynamic interplay between available resources and implementation climate across phases of implementation: a qualitative study of a VA national population health tool. Implement Sci Commun 2023; 4:74. [PMID: 37386501 DOI: 10.1186/s43058-023-00460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Available resources within an organization can determine the implementation success of an intervention. However, few studies have investigated how the required resources change over the phases of implementation. Using stakeholder interviews, we examined the changes in and interactions between available resources and implementation climate in the implementation and sustainment phases of a national implementation effort for a population health tool. METHODS We conducted a secondary analysis of the interviews with 20 anticoagulation professionals at 17 clinical sites in the Veterans Health Administration health system about their experiences with a population health dashboard for anticoagulant management. Interview transcripts were coded using constructs from the Consolidated Framework for Implementation Research (CFIR) and according to the phase of implementation (pre-implementation, implementation, and sustainment) as defined by the VA Quality Enhancement Research Initiative (QUERI) Roadmap. We analyzed the factors that may determine successful implementation by examining the co-occurrence patterns between available resources and implementation climate across different implementation phases. To illustrate the variations in these determinants across phases, we aggregated and scored coded statements using a previously published CFIR scoring system (- 2 to + 2). Key relationships between available resources and implementation climate were identified and summarized using thematic analysis. RESULTS The resources necessary to support the successful implementation of an intervention are not static; both the quantity and types of resources shift based on the phases of the intervention. Furthermore, increased resource availability does not guarantee the sustainment of intervention success. Users need different types of support beyond the technical aspects of an intervention, and this support varies over time. Specifically, available resources in the form of technological support and social/emotional support help users establish trust in a new technological-based intervention during the implementation phase. Resources that foster and maintain collaboration between users and other stakeholders help them stay motivated during sustainment. CONCLUSIONS Our findings highlight the dynamic nature of available resources and their impacts on the implementation climate across different phases of implementation. A better understanding of the dynamics of available resources over time from the users' perspectives will allow the adaptation of resources to better meet the needs of the intervention stakeholders.
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Affiliation(s)
- Ying-Jen Lin
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Allison Ranusch
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - F Jacob Seagull
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy B Sussman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA.
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5
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Mangrum JS, Saunders JA, Chaiyakunapruk N, Witt DM, King JB. A scoping review of direct oral anticoagulant ambulatory management practices. J Thromb Thrombolysis 2023; 55:700-709. [PMID: 36977918 DOI: 10.1007/s11239-023-02794-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
Models of care for managing direct oral anticoagulant (DOAC) therapy are evolving. Little is known of what services are provided by anticoagulation managements services (AMS) for DOACs, or what necessitates comprehensive DOAC management and what differentiates it from usual care. The purpose of this scoping review was to describe services, management, or monitoring of DOACs distinct from prescriber-managed or usual care of DOACs. This scoping review reported followed the 2018 Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews (PRISMA-ScR). We searched PubMed, CINAHL, and EMBASE from inception to November 2020 to identify articles of interest. No language restriction was applied. Articles were included if they provided a description of DOAC management services, and described longitudinal anticoagulation follow-up that occurred in ambulatory care, community, or outpatient-related settings. Data was extracted from a total of 23 articles. The specific types of DOAC management interventions provided varied across the included studies. Nearly all studies described some form of DOAC therapy appropriateness assessment. Other common interventions included assessments of DOAC therapy compliance, adverse event triage and management, assessment of DOAC dosing appropriateness, periprocedural management of DOAC therapy, educational interventions, and renal function monitoring. A variety of DOAC management interventions were identified, but additional studies are needed to help health systems decide whether specific interventions performed by dedicated services are preferred over the usual care provided by clinicians prescribing DOAC therapy.
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Affiliation(s)
- Jasmine S Mangrum
- University of Washington School of Pharmacy, Seattle, WA, USA.
- Clinical Practice, University of Washington School of Pharmacy, South Campus Center | 1601 NE Columbia Rd, Suite 246A, Seattle, WA, 98195-7631, USA.
| | - John A Saunders
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Jordan B King
- Department of Population Health Sciences, University of Utah School of Medicine, 295 Chipeta Way, Williams Building, Salt Lake City, UT, 84108, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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6
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Wung JC, Lin HC, Hsu CC, Lin CC, Wang SY, Chang SL, Chang YL. Drug-related problem characterization and the solved status associated factor analysis in a pharmacist-managed anticoagulation clinic. PLoS One 2022; 17:e0270263. [PMID: 35969589 PMCID: PMC9377620 DOI: 10.1371/journal.pone.0270263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 06/08/2022] [Indexed: 12/01/2022] Open
Abstract
Drug-related problems (DRPs) in a pharmacist-managed anticoagulation clinic (AC) have not been extensively studied. We aimed to characterize the DRPs in a pharmacist-managed AC, identify the factors associated with the solved status of DRPs, and analyze the secondary outcomes, including the safety and efficacy of AC service. The patients receiving services at a pharmacist-managed AC in a medical center for the first time from March 2019 to August 2020 were reviewed retrospectively. The DRPs were retrieved from a self-developed Intelligent AC Service System and classified according to the Pharmaceutical Care Network Europe Foundation v9.0 classification system. Logistic regression models were performed to identify the potential factors associated with the solved status of DRPs. A total of 78 direct oral anticoagulant (DOAC) and 34 warfarin users were included. The major types of DRPs identified at the initial service were adverse drug events (ADEs) (68.4%) and untreated symptoms or indications (14.8%) in the DOAC group, and ADEs (51.6%) and suboptimal effect of drug treatment (38.7%) in the warfarin group. The rates of totally solved DRPs were 56.8% and 51.6% in the DOAC and warfarin groups, respectively. According to the multivariable analysis, receiving AC services 3 times or more in 180 days (OR 3.11, 95% CI 1.30–7.44) was associated with the totally solved status of DRPs in the DOAC group, but no relevant factor was identified in the warfarin group. The secondary outcomes showed that DOAC users demonstrated fewer thromboembolism events, major bleeding, and bleeding-related hospitalizations after AC services, whereas the warfarin users increased percentage time in therapeutic range (TTR% 55.0% vs. 74.6%, P = 0.006) after AC services. These findings may be utilized to develop DOAC and warfarin AC services.
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Affiliation(s)
- Ju-Chieh Wung
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Chung Lin
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chieh Lin
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Szu-Yu Wang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Department of Medicine, Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- * E-mail:
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7
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Saiyitijiang A, Aizezi M, Zhao Y, Gao Y. Efficacy and safety of new oral anticoagulants combined with antiplatelet drugs in the treatment of coronary heart disease: Systematic evaluation and meta-analysis. Ann Noninvasive Electrocardiol 2022; 27:e12977. [PMID: 35715952 PMCID: PMC9484016 DOI: 10.1111/anec.12977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To analyze the efficacy and safety of antiplatelet drugs combined with new oral anticoagulants (noac) in the treatment of coronary atherosclerotic heart disease (CAD). Methods The randomized controlled trials of noac combined with antiplatelet therapy in Cochrane, CNKI, PubMed, EMBASE, Wanfang, Google Scholar, and Baidu library were searched using the literature database. Two researchers independently searched and screened to ensure the consistency of the results, and the literature was summarized and analyzed by Revman 5.3 software. Results Five research results were included. The results showed that the incidence of mace [95% CI 0.75–0.95, or = 0.84,p = .04], the incidence of major and minor bleeding [95% CI 1.25–5.16, or = 2.54,p = .01], the mortality of cardiovascular disease [95% CI 0.78–0.96, or = 0.86, p = .05], the total mortality [95% CI 0.79–0.95, or = 0.87, p = .003], and the incidence of myocardial infarction in patients with CAD treated with noac and antiplatelet drugs [95% CI 0.77–0.95, or = 0.85, p = .004] was lower than that treated with antiplatelet drugs alone, and the difference was statistically significant (p < .05); the incidence of fatal bleeding [95% CI 0.81–2.08, or = 1.30, p = .28], the incidence of stroke [95% CI 0.50–1.03, or = 0.71, p = .07], and the incidence of intracranial hemorrhage [95% CI 1.02–2.56, or = 1.61, p = .06]. There was no significant difference with antiplatelet drugs alone (p > .05). Conclusion Noac combined with antiplatelet drugs can reduce mace, total mortality, the incidence of myocardial infarction, and cardiovascular mortality in patients with CAD, but may increase the risk of bleeding.
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Affiliation(s)
- Alimila Saiyitijiang
- The Heart Center of the First Affiliated Hospital of Xinjiang Medical University, Urumuqi, China
| | - Mayila Aizezi
- The Third Departments of the First People's Hospital of Urumqi, Urumuqi, China
| | - Ying Zhao
- The General Practice Department of the Third People's Hospital of Xinjiang Uygur Autonomous Region, Urumuqi, China
| | - Ying Gao
- The Third Departments of the First Affiliated Hospital of Xinjiang Medical University, Urumuqi, China
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8
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Damschroder LJ, Sussman JB, Pfeiffer PN, Kurlander JE, Freitag MB, Robinson CH, Spoutz P, Christopher MLD, Battar S, Dickerson K, Sedgwick C, Wallace-Lacey AG, Barnes GD, Linsky AM, Ulmer CS, Lowery JC. Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients. Implement Sci Commun 2022; 3:53. [PMID: 35568903 PMCID: PMC9107220 DOI: 10.1186/s43058-022-00297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. Methods For each trial, we will recruit 8–12 clinics (24–36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. Process. (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. Discussion MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. Trial registration ClinicalTrials.gov: NCT05065502. Registered October 4, 2021—retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00297-z.
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Affiliation(s)
- Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
| | - Jeremy B Sussman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Jacob E Kurlander
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Michelle B Freitag
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Claire H Robinson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, WA, USA
| | - Melissa L D Christopher
- Pharmacy Benefits Management Services, Veterans Health Administration, 810 Vermont Ave NW, Washington DC, 20420, USA
| | - Saraswathy Battar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | | | - Christopher Sedgwick
- Department of Veterans Affairs, VA Heartland Network (VISN 15), Kansas City, MO, USA
| | | | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Amy M Linsky
- Section of General Medicine, VA Boston Healthcare System, Boston, MA, USA.,Center for Health Organizations and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Julie C Lowery
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
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9
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Barnes GD, Sippola E, Ranusch A, Takamine L, Lanham M, Dorsch M, Sales A, Sussman J. Implementing an electronic health record dashboard for safe anticoagulant management: learning from qualitative interviews with existing and potential users to develop an implementation process. Implement Sci Commun 2022; 3:10. [PMID: 35109916 PMCID: PMC8812192 DOI: 10.1186/s43058-022-00262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Facilitating appropriate care delivery using electronic health record (digital health) tools is increasing. However, frequently used determinants frameworks seldom address key barriers for technology-associated implementation. METHODS Semi-structured interviews were conducted in two contexts: the national Veterans Health Affairs (VA) following implementation of an electronic dashboard, a population health tool, and the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) prior to implementation of a similar electronic dashboard. The dashboard is designed for pharmacist or nurse use to monitor safe outpatient anticoagulant prescribing by physicians and other clinicians We performed rapid qualitative inquiry analysis and selected implementation strategies. Through a stakeholder focus group session, we selected implementation strategies to address determinants and facilitate implementation in the MAQI2 sites. RESULTS Among 45 interviewees (32 in VA, 13 in MAQI2), we identified five key determinants of implementation success: (1) clinician authority and autonomy, (2) clinician self-identity and job satisfaction, (3) documentation and administrative needs, (4) staffing and work schedule, and (5) integration with existing information systems. Key differences between the two contexts included concerns about information technology support and prioritization within MAQI2 (prior to implementation) but not VA (after implementation) and concerns about authority and autonomy that differed between the VA (higher baseline levels, more concerns) and MAQI2 (lower baseline levels, less concern). CONCLUSIONS The successful implementation of electronic health record tools requires unique considerations that differ from other types of implementation, must account for the status of implementation, and should address the effects of the tool deployment on clinical staff authority and autonomy. Interviewing both post-implementation and pre-implementation users can provide a robust understanding of implementation determinants.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA. .,Center for Behavioral and Social Sciences in Medicine, University of Michigan, Ann Arbor, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.
| | - Emily Sippola
- Center for Behavioral and Social Sciences in Medicine, University of Michigan, Ann Arbor, USA
| | - Allison Ranusch
- Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA
| | - Linda Takamine
- Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA
| | - Michael Lanham
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
| | - Michael Dorsch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,College of Pharmacy, University of Michigan, Ann Arbor, USA
| | - Anne Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
| | - Jeremy Sussman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,Center for Clinical Management Research, Ann Arbor Veterans Health Affairs, Ann Arbor, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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Dietrich E, Davis K, Talana A, Holland N, Akhavan N, Panna D, Wright A, Huber K. Three‐year clinical interventions from an outpatient multidisciplinary direct oral anticoagulant monitoring service. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eric Dietrich
- University of Florida College of Pharmacy, Gainesville Florida
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
| | - Kyle Davis
- United Therapeutics, Durham North Carolina
| | - Amy Talana
- Center for Living Well, Kissimmee Florida
| | - Neal Holland
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
| | - Neeka Akhavan
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
| | - Danielle Panna
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
| | - Ashleigh Wright
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
| | - Katherine Huber
- UF Internal Medicine at Tower Hill University of Florida College of Medicine, Gainesville Florida
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11
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Allen AL, Lucas J, Parra D, Spoutz P, Kibert JL, Ragheb B, Chia L, Sipe A. Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants. J Am Heart Assoc 2021; 10:e022758. [PMID: 34796718 PMCID: PMC9075229 DOI: 10.1161/jaha.121.022758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60‐year standard of care from one‐to‐one provider‐to‐patient anticoagulation monitoring to a population‐based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.
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Affiliation(s)
- Arthur L Allen
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT
| | - Jessica Lucas
- North Florida/South Georgia Veterans Affairs Health Care System Gainesville FL
| | - David Parra
- Pharmacy Benefits Management Veterans Integrated Service Network 8 Bay Pines FL.,University of Minnesota College of Pharmacy Minneapolis MN
| | - Patrick Spoutz
- Pharmacy Benefits Management Veterans Integrated Service Network 20 Vancouver WA
| | | | - Bishoy Ragheb
- Veterans Affairs Tennessee Valley Health System Murfreesboro TN
| | - Linda Chia
- Pharmacy Benefits Management Veterans Integrated Service Network 8 Bay Pines FL
| | - Amy Sipe
- Academic Detailing Veterans Integrated Service Network 15 Kansas City MO
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12
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Fantoni C, Bertù L, Galliazzo S, Pola R, Pomero F, Porfidia A, Porreca E, Valeriani E, Ageno W. Follow-up management of patients receiving direct oral anticoagulants. Intern Emerg Med 2021; 16:571-580. [PMID: 32661795 DOI: 10.1007/s11739-020-02433-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/02/2020] [Indexed: 12/01/2022]
Abstract
Over the last years, direct oral anticoagulants (DOACs) have radically changed and simplified the therapeutic approach and management of patients on anticoagulant therapy. For these patients, international guidelines recommend to set up a regular follow-up (every 1-6 months) to re-enforce education, to ensure adequate adherence and persistence to treatment. In real-life setting, the application of the suggested follow-up regimens and incidence rates of thrombotic and bleeding complications related to the intensity of follow-up strategies has not been described. We conducted a multicentre, retrospective study at 4 Italian Thrombosis Centres to describe follow-up strategies of patients on DOACs treatment and to assess the incidence of bleeding and thrombotic complications. We enrolled 534 patients, with median follow-up 24 months: 52.1% had < 3 visits/year (group 1), while 47.9% required ≥ 3 visits/year (group 2). Mean age and gender were similar between the 2 groups, while severe anaemia (4.4% and 1.2%, p 0.03) and creatinine clearance < 50 mL/min were more common in group 2 (26.8% and 17.8%, p 0.02). The incidence of thromboembolic events was 3.9% in group 2 and 1.1% in group 1 (p 0.03). Major bleeding rates were non-significantly higher in group 2, whereas non-major bleeding rates occurred significantly more frequently in group 2 (26.6% and 18.7%, respectively, p 0.03). A tailored follow-up program is of critical importance to correctly manage patients on DOACs. A less intense follow-up management is feasible and safe for a substantial proportion of patients, provided they are carefully identified at specialized centres.
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Affiliation(s)
- Chiara Fantoni
- Department of Medicine, Maggiore Hospital, Bologna, Italy.
| | - Lorenza Bertù
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - Silvia Galliazzo
- Internal Medicine Department, San Valentino Hospital, Montebelluna, Treviso, Italy
| | - Roberto Pola
- A. Gemelli University Hospital IRCCS, Rome, Italy
| | - Fulvio Pomero
- Internal Medicine Department, S. Lazzaro Hospital, Alba, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Walter Ageno
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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13
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Rossier C, Spoutz P, Schaefer M, Allen A, Patterson ME. Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management. J Thromb Thrombolysis 2020; 52:200-208. [PMID: 33222115 DOI: 10.1007/s11239-020-02341-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
Inappropriate direct acting oral anti-coagulants (DOAC) prescribing increases the risk of adverse events. Population health management tools (PMTs) could help reduce adverse events through the early, efficient identification of questionable prescribing practices, but the impact of such a tool remains unknown. We evaluated the effect of PMT use on questionable DOAC dosing rates within 40 VHA medical centers and whether this effect differed by DOAC indication or agent. Medical centers were divided into PMT user or standard of care (SOC) groups based upon high or low tool access in the prior year. Questionable DOAC dosing rate was defined as the proportion of patients prescribed DOACs who were also flagged by the tool. Chi-square tests were used to determine if PMT user versus SOC groups differed with high (above 15.3%) versus low (below 15.3%) questionable dosing rates. T-tests were used to determine if mean questionable dosing rates significantly differed between the PMT user and SOC groups. DOAC PMT users were classified less frequently as being 'High" questionable dosage rate compared to SOCs (25% PMT vs. 75% SOC, respectively, p = 0.002). DOAC PMT utilization within the overall cohort was associated with a 4.3% absolute reduction in questionable DOAC dosing rates (13.2% PMT vs 17.5% SOC; p = 0.01). Tool use within the atrial fibrillation (AF) subgroup was associated with a 5.1% absolute reduction in questionable dosing rates (10.4% SOC vs. 5.3% PMT, p < 0.001). Tool use was also associated with lower questionable dosing rates in the apixaban (p < 0.001), dabigatran (p = 0.03) and AF plus venous thromboembolism (p < 0.001) subgroups. In our study, PMT use was associated with reduced questionable DOAC dosing, a difference most pronounced within AF patients. A population health approach has the potential to reduce adverse events among patients prescribed DOACs.
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Affiliation(s)
- Connor Rossier
- Central Virginia VA Health Care System, Richmond, VA, USA
| | - Patrick Spoutz
- Department of Veterans Affairs VISN #20, VA Northwest Health Network, Vancouver, WA, USA
| | - Monica Schaefer
- Department of Veterans Affairs VISN #15, VA Heartland Network, Kansas City, MO, USA
| | - Arthur Allen
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Mark E Patterson
- Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, 4245 Health Sciences Building, Kansas City, MO, 64108-2718, USA.
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Barnes GD, Sippola E, Dorsch M, Errickson J, Lanham M, Allen A, Spoutz P, Sales AE, Sussman J. Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol. Implement Sci 2020; 15:83. [PMID: 32958020 PMCID: PMC7504868 DOI: 10.1186/s13012-020-01044-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Geoffrey D Barnes
- University of Michigan Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA.
| | - Emily Sippola
- University of Michigan Center for Bioethics and Social Science in Medicine, Ann Arbor, USA
| | - Michael Dorsch
- University of Michigan School of Pharmacy and Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | - Joshua Errickson
- University of Michigan Center for Statistical Consultation and Research, Ann Arbor, USA
| | - Michael Lanham
- University of Michigan Department of Learning Health Sciences, Ann Arbor, USA
| | - Arthur Allen
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, USA
| | - Anne E Sales
- University of Michigan Department of Learning Health Sciences, Institute for Healthcare Policy and Innovation, and Ann Arbor Veterans Health Affairs Center for Clinical Management and Research, Ann Arbor, USA
| | - Jeremy Sussman
- University of Michigan Department of Internal Medicine, Institute for Healthcare Policy and Innovation, and Ann Arbor Veterans Health Affairs Center for Clinical Management and Research, Ann Arbor, USA
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