Introducing DOACs to Your Anticoagulation Service LYNN OERTEL, MS, NP-BC, CACP ANTICOAGULATION MANAGEMENT SERVICE MASSACHUSETTS GENERAL HOSPITAL
Challenges at the start. Consensus / agreement among stakeholders that this is the right thing to do Technical changes related to DOAC modules and hospital systems Staff hesitancy already busy enough Knowledge gaps and need for staff education No quality examples of how to do this
DOAC vs. warfarinwithin Loyal Cohort* *Loyal Cohort = patients receiving primary care at MGH Source: MGH Fireman Vascular Center
Clinical staff education curriculum Blended learning experience Credit hours awarded (5.66 from Knight Center and 1 from online program)
Required reading assignments RUFF CT ET AL. THE AMERICAN JOURNAL OF MEDICINE (2016) 129, S1-S29 BURNETT AE ET AL. J THROMB THROMBOLYSIS (2016) 41:206 232
Identify knowledge gaps and needs Pre and Post knowledge assessments (AMS staff required to achieve 100% on post test) 23 multiple-choice items Post-assessment open book 120 100 80 60 Pre-assessment results score GOAL 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
DOAC Referral Cascading options presented according to: Indication Drug/dose options Transitioning, if applicable Off label use statement RN staff worksheet to confirm eligibility
Standard Follow-up Plan
DOAC List view Date filter = Today Televoxautomated calls made 2 days prior to patient s scheduled QNR F/U date Patient s response used to indicate confirmation of availability F/U QNRs average 5-10 minutes
Patient and Family Education Slideshow Caveats: MGH experience thus far with warfarin patients transitioning to a DOAC Education by phone (packet mailed in advance) Average time on phone ~ 22 minutes
Updated Medication Guides Find in: Partners Handbook or EED anticoag portal page Spanish translations available. English and Spanish MGH Instructions can be accessed in Epic.
Revision of existing Patient Agreement to incorporate DOACs
DOACs At-a-Glance Reference
DOAC POTENTIALinteracting drugs
Follow-up QNRs: A broader assessment of patient is needed and includes adherence and medication changes (as noted in QNR) but also: Hospitalized/ED visit for what reason and when Interruption in DOAC therapy (and details) that AMS unaware of? Seen by MD other than well visits Any side effects? (assess if bruising increased on DOAC when compared with warfarin experience) Verification of change in dose as expected (for new VTE type indications only: Apixon Day 8 of trtand Riva on Day 22 of Trt) Check on refills provided with initial Rx how many refills? Issues with drug procurement/financial concerns about getting refills as needed? Dawn F/U QNRs: Adherence* use 80% rule Medication surveillance for potentially interacting meds*that may require dose adjustment or avoid use Dawn Lab QNRs*: egfr, Creatinine and Hctobtained per Standard F/U plan (manual process now, future: via lab interface) Adverse events documented in Events Tab Procedures documented in Procedures Tab Above assessment captured and documented in Epic Tel Encounter *-This information displayed in AMS icon via Outbound Interface message along with next scheduled F/U date
How do I make an assessment of DOAC adherence?
Adherence (mark as non-adherent) Adherence reflects the manner in which patients take their medications relative to the agreed regimen with the prescriber (NICE, 2009) Considered adherent if take medication as prescribed more than 80% of the time (WHO, 2003).dadNO= During today's follow-up, patient reports missing _ doses over past. Importance of not missing any doses was reinforced and interventions explored to improve adherence. Based on adherence concerns, follow-up in 1 month...dadyes= During a phone call follow-up today, patient accurately described dose and adherence with taking as prescribed.
AMS DOAC Icon
Pilot evaluation to demonstrate value to organization Adherence (patient reported) Renal Function or drop in Hctnecessitating a dose change or avoid use Identification of Drug Interactions which may require a change in therapy Adverse events Optimal management of transitions/interruptions in care Patient experience