Assessment of a Best Practice Alert and Referral Process for Preprocedure Antithrombotic Medication Management for Patients Undergoing Gastrointestinal Endoscopic Procedures

Abstract

IMPORTANCE Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety. OBJECTIVE To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures. DESIGN, SETTING, AND PARTICIPANTS This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019. EXPOSURES Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017. MAIN OUTCOMES AND MEASURES The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level. RESULTS A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02).

Improving preprocedure antithrombotic management: Implementation and sustainment of a best practice alert and pharmacist referral process

“… 21 As described previously, a diverse group of stakeholders was intimately involved in the development and pilot of this process. 12 While our system did require additional FTE pharmacist effort to handle the additional volume, we have previously shown that fewer cancellations resulting from this referral and review process would result in significant cost savings to the hospital system and would more than cover the additional costs. 12 …”

“…Furthermore, other clinics that have explored this preprocedure management process have found it to be feasible 21 . As described previously, a diverse group of stakeholders was intimately involved in the development and pilot of this process 12 12 …”

“…As described previously, a diverse group of stakeholders was intimately involved in the development and pilot of this process 12 12 …”

“…A new BPA and anticoagulation clinic referral process was implemented within our EMR system (Epic) starting in November 2017 as a pilot in one gastroenterology clinic and one primary care clinic in a single health care system in a Midwestern state in the United States. 12 It was gradually expanded over the subsequent 5 months until it was implemented system‐wide in April 2018. This BPA (Figure S1 ) is triggered when an outpatient elective GI endoscopy procedure is ordered in the EMR for a patient listed as taking an oral anticoagulant or an antiplatelet medication (other than aspirin).…”

“…A new BPA and anticoagulation clinic referral process was implemented within our EMR system (Epic) starting in November 2017 as a pilot in one gastroenterology clinic and one primary care clinic in a single health care system in a Midwestern state in the United States 12 . It was gradually expanded over the subsequent 5 months until it was implemented system‐wide in April 2018.…”