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DOAC Clinics Benefit Patients and Referring Physicians

July 26, 2022

August 2022

Since their introduction in 2010, direct oral anticoagulants (DOACS) have been an increasingly used therapy for patients who require anticoagulation. DOACs have advantages over warfarin in terms of fixed dosing, shorter half-life, and more predictable pharmacokinetics and drug interactions, as well as their lack of need for routine coagulation monitoring. However, they are still high-risk medications that require adjustments in some patients based on changing clinical parameters and planning when given prior to medical procedures.

Anticoagulation clinics can provide expert support that benefits both patients taking DOACs and their referring physicians. In fact, guidance from the Anticoagulation Forum strongly recommends implementing specialized DOAC services.1 A study in Research and Practice in Thrombosis and Homeostasis describes how members of a pharmacist-led, remote, telephone-based anticoagulation clinic at Brigham and Women’s Hospital in Boston, have modified their services since their initial inclusion of DOAC management in 2017 to better optimize patient outcomes while making better use of pharmacists’ time.2,3

Study author Katelyn W. Sylvester, PharmD, of Brigham and Women’s, pointed out regulatory and safety bodies have been bringing attention to the importance of good safety management for DOACs, which these clinics can help promote. For example, the nonprofit Joint Commission revised its National Patient Safety Goals on anticoagulation in 2019, emphasizing the need to design care systems that ensure the safety of patients taking DOACs.4

Among other roles, the anticoagulation clinic at Brigham and Women’s educates patients; helps select the DOAC best suited to new patients; assesses medication adherence and provides patients tools to improve it; assists with medication procurement (e.g., with insurance prior authorizations); checks for thromboembolism, bleeding, and other side effects; and evaluates new medications, labs, and patient parameters that might influence dosing (e.g., kidney and liver function, patient weight). In addition to its telephone visitation services, the clinic offers a 24-hour on-call pager for minor bleeding so patients can reach out if they need to be assessed.

The clinic also provides perioperative management around DOACs, which Dr. Sylvester noted is often stressful and burdensome for physicians to manage, and sometimes lack of proper planning even results in delayed medical procedures. In a survey given to 110 attendings across Brigham and Women’s, Dr. Sylvester and colleagues found such periprocedural management to be one of the most helpful aspects of the clinic, along with help in transitioning patients to or from warfarin. They also found that the clinic’s DOAC services decreased their daily workload.

Since the initial addition of DOACs to the clinic, the team at Brigham and Women’s has further refined its approach to patient management. After the first six months of active management by the clinic, patients were stratified based on their risk of adverse events, medication barriers, and potential need for medication adjustments, with some patients receiving active surveillance by the clinic for longer periods of time. Such an approach helps optimize patient contact while allowing clinic resources to extend farther.

“I think the balance is not overmanaging them,” Dr. Sylvester said. “One of the pieces of advice we were given was to meet with patients frequently at first to build trust, but then to back off.”

Over four years, the clinic has managed 1,622 patients through 3,154 DOAC encounters, requiring 986 interventions by pharmacists. Although 87.5% of physician survey respondents found the clinic valuable in improving quality and safety of patient anticoagulation care, some still found a barrier in terms of the time needed to submit a clinic referral.

Dr. Sylvester sees the reduction in physician workload related to, for instance, managing minor bleeding and preprocedural planning as a key benefit of the clinic.

“[Primary care physicians] and cardiologists are doing such a lot,” she said. “Having someone else who is focused on anticoagulation – someone looking at what is changing in the patient through that lens – that’s really helpful.”

Any conflicts of interest declared by the authors can be found in the original article.

References

  1. Burnett AE, Mahan CE, Vazquez SR, Oertel LB, Garcia DA, Ansell J. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis. 2016;41(1):206-232.
  2. Sylvester KW, Ting C, Lewin A, et al. Expanding anticoagulation management services to include direct oral anticoagulants. J Thromb Thrombolysis. 2018 Feb;45(2):274-280.
  3. Sylvester KW, Chen A, Lewin A, et al. Optimization of DOAC management services in a centralized anticoagulation clinic. Res Pract Thromb Haemost. 2022;6(3):e12696.
  4. The Joint Commission. Managing the risks of direct oral anticoagulants. Sentinel Event Alert. 2019;(61):1-5.

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