Screening Tool to Reduce Anticoagulant Clinic Encounters
Objective: Patients prescribed warfarin for the prevention of stroke in atrial fibrillation at the Fayetteville Veterans Affairs Heath Care Center are managed by a clinical pharmacy specialist (CPS) in the Anticoagulation Clinic. Patients prescribed a direct oral anticoagulant (DOAC) for the same indication are followed by a CPS within the patient aligned care team. A screening tool was developed to identify candidates who could switch from warfarin to DOAC therapy. The purpose of this quality improvement project was to determine the impact of a screening tool on the average number of monthly Anticoagulation Clinic encounters.
Methods: The impact of the screening tool to effect the num ber of clinic encounters was studied for 3 months prior to and 2 months following an 8-week screening period. The screening tool, created to determine the eligibility of patients to switch to DOAC, was developed based on US Department of Veterans Affairs Pharmacy Benefits Management Service guidance. Eligible patients were counseled on DOACs and given the opportunity to shift therapies. The total number of encounters associated with all anticoagulant patients, including those who changed to DOACs, was recorded.
Results: During the 3 months prior to screening, an average of 476 encounters per month were documented. For 2 months following screening, an average of 546 encounters per month were recorded. Seventy additional monthly encounters were observed after the screening tool implementation ( P = .15). Thirty patients chose to switch to DOAC therapy; there were 75 fewer encounters among these 30 patients in the postscreening period, a reduction of 70.1% ( P = .01).
Conclusions: The DOAC screening tool was unsuccessful in reducing the overall number of Anticoagulation Clinic encounters. However, it was determined that when patients switched from warfarin to a DOAC, encounters were reduced. Several confounding factors influenced study results.
Discussion
The general results of this quality improvement project showed that implementation of a screening tool designed to identify patients eligible for DOAC therapy did not decrease the average number of Anticoagulation Clinic encounters. Thirty of 82 eligible patients (36.6%) decided to switch to DOAC therapy during the study period. For those 30 patients, there was a statistically significant decrease in the number of individual clinic encounters. This suggests that the screening tool may positively impact Anticoagulation Clinic metrics when evaluating individual patients, potentially increasing clinic appointment availability.
Confounding Factors
Multiple confounding factors may have affected this project’s results. First, Class I recall for point-of-care test strips used by the clinic was mandated by the US Food and Drug Administration on November 1, 2018.5 Before the recall, investigators found that many nontherapeutic INRs using point-of-care testing later showed results that were within the therapeutic INR range using same-day venous blood collection. This may have led to increases in falsely recorded nontherapeutic INRs and lowered TTR report results. Initially, the project was designed to collect monthly clinic encounter data for 3 months following the 8-week screening period; however, data collection was stopped after 2 months because of the test strip recall.
In addition, in early December 2018, all patients were moved from the Anticoagulation Clinic to the Anticoagulation Telephone Clinic that uses venous blood draws and telephone appointments. Data from venous blood draw results had previously been excluded from this project because results were not available on the same day. Patients in this program are contacted by telephone rather than being offered a face-to-face appointment, thus reducing in-clinic encounters.
Another confounding factor was a FVAHCC policy change in August 2018 requiring that any patient initiated on a DOAC make a onetime visit to the Anticoagulation Clinic prior to establishing care with a PACT CPS. Investigators were unable to exclude these patients from monthly encounter data. Some patients transitioning from warfarin to DOAC therapy were required to continue receiving anticoagulation monitoring from the clinic because of limited PACT CPS clinic availability, thus further increasing postscreening encounters.
Health care providers outside of the Anticoagulation Clinic and uninvolved with the quality improvement project also were switching patients from warfarin to DOAC therapies. Although this may have affected encounter data positively, investigators cannot guarantee these patients would have met criteria outlined by the screening tool.
In September 2018 Hurricane Florence disrupted health care delivery during the 8-week screening period. This event disrupted numerous clinic appointments. Although screening of patients was completed during the 8-week screening period, some patients did not switch to DOAC therapies until November 2018.
Secondary Endpoint Results
Promising results can be seen by specifically looking at the secondary endpoint: the number of encounters associated with patients who chose DOAC therapy. There were 107 encounters associated with the 30 patients who switched to a DOAC prior to screening and only 32 associated encounters after screening, a reduction of 70.1%. This suggests that multiple appointment slots were freed when the screening tool led to successful conversion from warfarin to a DOAC. Further assessment is warranted.
