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.
Future Project Development
Future areas for quality improvement project development include expanding project criteria to include patients taking warfarin for VTE. Eighty-nine of 137 patients (65%) who were deemed ineligible to switch to DOAC therapy were excluded due to a diagnosis of VTE. There are existing VA/Department of Defense Criteria for Use for DOAC use in VTE recommendations. Straightforward modification of the screening tool could include this patient group and may be especially useful for patients on indefinite warfarin therapy for recurrent VTE who have poor TTR report results.6
Given the number of confounding factors caused by unforeseen changes to the Anticoagulation Clinic workflow, use of the DOAC screening tool was placed on hold at the conclusion of data collection. This limited the ability to analyze encounter data in the months following project conclusion. Future plans include reimplementation of the screening tool with minor adjustments to include patients on warfarin for VTE and patients with a TTR report results above 60%.
Conclusion
This quality improvement project sought to determine the impact of a screening tool on effecting Anticoagulation Clinic encounter metrics. Results of this project show that the screening tool was unsuccessful in reducing the number of overall clinic encounters. Some promise was shown when evaluating clinic encounters for patients who switched anticoagulation therapies. Numerous confounding factors may have contributed to these results.
