Category: Federal Forum Posters
Purpose: The use of direct oral anticoagulants (DOACs) for the management of atrial fibrillation and venous thromboembolism has significantly increased in recent years. Ease of use, clinical efficacy, and decreased monitoring requirements offer significant benefit to those who are not candidates for alternative agents. Although therapy with these agents is often less burdensome, it is still necessary to ensure proper agent selection, dosing, and monitoring. The optimal strategy for reviewing and monitoring DOAC therapy at the Boise Veterans Affairs Medical Center (BVAMC) is currently unknown.
Methods: The implementation of a DOAC Population Management Tool (PMT) at the BVAMC allowed clinical pharmacists to monitor patients identified as having possible benefit from pharmacist intervention. This tool “flags” patients with certain points of clinical interest regarding DOAC monitoring, including inappropriate dosing, drug interactions, missing laboratory values, and refill history, among others. Clinical team pharmacists were responsible for acting on these PMT flags and intervening in therapy, or dismissing them if no appropriate intervention could be made. A prospective medication use evaluation (MUE) was performed to evaluate these pharmacist interventions. The primary endpoint was intervention rates from flags identified by the PMT. Secondary endpoints included types of interventions made, number of interventions dismissed from flags identified by the PMT, and types of intervention flags dismissed. All patients flagged on the date of PMT implementation (12/27/17) were included. Patients flagged by the PMT after 12/27/17 were excluded. Descriptive statistics were used to evaluate the data from this MUE. Rates were calculated to describe what types of flags were identified and what interventions were made. Institutional Review Board approval was not required for the MUE.
Results: Of the 644 patients on a DOAC at the Boise VAMC, there were 305 flags identified by the PMT on 12/27/17 distributed across 239 distinct patients. The most common flag was “inappropriate dosing,” at a rate of 28%, followed by “4 weeks late for refill,” at 20%. An intervention was made for 50% (n=157) of all flags, while 19% (n=58) of flags were dismissed by the pharmacist. The most common intervention was ordering of laboratory work at 22.4%. The third most common intervention was a change in DOAC dose, at 14.5% percent. Of all the interventions made, 31% results in significant change in therapy. A significant change in therapy was considered to be stopping, switching, or dose adjusting a DOAC, or the identification of a critical drug interaction.
Conclusion: The results of this MUE show that with use of the DOAC PMT, clinical pharmacists are making significant interventions in DOAC therapy and monitoring, at a rate of 50%. With promising results like these, the use of the PMT should continue at the Boise VAMC. The use of this tool should also be distributed to other clinical staff, including anticoagulation clinic nurses, so the responsibility of DOAC monitoring can be shared between team members. When the monitoring process is fine-tuned, consideration should be given to expanding PMT use to other VA facilities.
Ianitza Bankova– PGY2 Pharmacy Resident â€“ Ambulatory Care, Boise VA Medical Center, Boise, ID