Optimizing Warfarin and Dual Oral Anticoagulation Practices in an Academic Clinic During a Merger Amid the COVID-19 Pandemic in a Marginalized Population.

Optimizing Warfarin and Dual Oral Anticoagulation Practices in an Academic Clinic During a Merger Amid the COVID-19 Pandemic in a Marginalized Population.

Publication date: Sep 20, 2024

The closure of a pharmacy-led anticoagulation clinic, which provided point-of-care (POC) INR testing and face-to-face visits, coupled with the transition to an academic physician-led clinic without POC INR testing and reliant on telephone communication, created significant challenges for warfarin management during the COVID-19 pandemic. The aim of this quality control (QC) project was to increase the percentage of patients on warfarin within the optimal Time in Therapeutic Range (TTR) from 52. 30% to 65. 00%, sustain baseline quarterly cumulative percentage TTR to 59. 00% and transition 20% of eligible patients from warfarin to Dual Oral Anticoagulation (DOAC) within 12 months. A multidisciplinary team employed a Fishbone diagram, stakeholder analysis, process flow map, and driver diagram. Significant barriers included knowledge gaps, fear of blood draws, lack of POC INR testing, and non-interoperable electronic health records. Primary outcome measures included quarterly cumulative percentage TTR, two monthly percentage TTR and the percentage of eligible patients switched to DOAC. Process measures included INR completion rates. Key interventions involved educating patients and the care team, transitioning patients to DOAC, improving electronic health records, and optimizing processes. Data analysis utilized run charts. Monthly INR completion rates rose from 63% to 87% within 12 months and reached 92% during the 6-month post-project period. Among 143 patients, 40. 55% (58) were eligible for a DOAC switch, with 51. 72% (30/58) successfully transitioning during the project and the 6-month post-project period. 2 Monthly TTR rates improved from the baseline of 52. 30% to 62. 00% during the study period and remained sustainable at 62. 80% in the post-project phase. Quarterly cumulative TTR rates remained stable at 59. 20% during study period in 2021. The quarterly cumulative TTR rates continued to increase at 60. 50% and 64. 40% in 2022 and 2023 respectively, during the post-project period. No bleeding episodes occurred during the 15-month post-project period. Multi-faceted strategies significantly improved warfarin safety during the project and maintained these improvements for 24 months. Transitioning from warfarin to DOACs was crucial for optimizing anticoagulation management with limited resources. The lead physician and team used various tools to address barriers to effective warfarin management, ensure appropriate DOAC prescribing, and enhance practices for DOAC prescriptions. This project effectively addressed barriers, improved population health, and provides a model for anticoagulation management in primary care settings.

Concepts Keywords
Academic COVID-19 Pandemic
Fishbone health care disparity
Monthly Oral Anticoagulation
Pandemic Population health
Pharmacy Quality Control
warfarin

Semantics

Type Source Name
drug DRUGBANK Warfarin
disease MESH COVID-19 Pandemic
disease IDO quality
disease IDO process
disease MESH fear of blood
disease MESH bleeding

Original Article

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