Leaders: Preventing Hemorrhage Through Research, Team Care
HN: What does the Anticoagulation Clinic at UCSF do, and how is this different from how anticoagulation is managed at other hospitals?
DR. FANG: Our anticoagulation clinic manages about 600 patients taking chronic anticoagulants. It’s staffed by nurse practitioners and pharmacists who are all trained in anticoagulant management and in our anticoagulation protocols. As the medical director, I’m the only physician who is part of this clinic, and I serve in more of a supervisory role in which I can provide clinical input where needed and help develop standardized protocols and practice patterns. Many of the anticoagulation clinics are built in similar ways.
In the past, much of the anticoagulation management was handled by individual practitioners, such as primary care physicians. But there was an increasing body of literature to support the use of anticoagulation clinics, so now many larger institutions have an anticoagulation management service and an anticoagulation clinic. Some may have physicians working there, but I think that the majority have an interdisciplinary team with pharmacists and nurse practitioners managing most of the patients.
HN: What’s the role of the hospitalist in anticoagulation management?
DR. FANG: Hospitalists pay quite a lot of attention to transitions of care. Attending on the medical service, I understand a little bit about both what people know and what they don’t know about the referral and transitions processes when moving someone to an outpatient anticoagulation clinic. I serve as a liaison and try to think of ways to smooth that transition.
HN: What are the future research areas that are ripe to explore in the anticoagulation field?
DR. FANG: One of the most exciting areas is the development of newer anticoagulants that do not require the frequent blood tests and monitoring that warfarin does. Right now, our anticoagulation clinic exists because warfarin is very challenging to manage and requires very frequent visits. There are newer anticoagulants such as dabigatran and rivaroxaban and several others that are in the pipeline that may obviate the need for warfarin and therefore for anticoagulation clinics.
We know these newer agents seem as good as, if not better than, warfarin in very controlled settings and clinical trials, but we don’t know how they work in the potentially sicker, more difficult to manage populations that we see in the real world. There are certain indications and certain comorbidities that should make clinicians really cautious about using these agents. For instance, we don’t know these agents would perform in older individuals or in those who have renal disease. It’s important to figure out how clinicians are prescribing and using these medications, who they are using them in, and whether the outcomes in the real world are as good as those we’ve seen in clinical trials.
Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.
