Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants

Abstract

Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60‐year standard of care from one‐to‐one provider‐to‐patient anticoagulation monitoring to a population‐based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.

Optimization of DOAC management services in a centralized anticoagulation clinic

“…Various models for centralized DOAC management have been reported, ranging from the traditional anticoagulation clinic models where patients are seen in clinic or through telephone encounters on a regular interval of 3 to 6 months to a population health model that leverages technology to identify patients who require intervention. 12 , 13 Our management plan is more of a hybrid approach that provides a more traditional model for the first 6 months and then stratifies patients on the basis of the potential need for a dose adjustment to determine the subsequent follow‐up intervals. All patients remain in active in our clinic so that we can provide education, on‐call support, oversight of procedure plans, yearly assessment of bleeding and clotting risk, refilling prescriptions, completing necessary prior authorizations, and ordering labs as needed.…”

“…In 2016, the Anticoagulation Forum published guidance on the management of the DOACs in venous thromboembolism (VTE) treatment, which included a strong recommendation for implementing specialized inpatient and outpatient DOAC anticoagulation services 11 . Previous publications have also proposed models for outpatient DOAC management 12‐15 …”

“…11 Previous publications have also proposed models for outpatient DOAC management. [12][13][14][15] As AMS models expand to incorporate DOAC management, barriers remain. Lack of provider awareness for services provided by the clinic, budgetary challenges, and scope of care of anticoagulation staff pose potential barriers to optimizing the level and the quality of care.…”

“… 11 Previous publications have also proposed models for outpatient DOAC management. 12 , 13 , 14 , 15 …”

“…Pharmacists in the DOAC service can provide baseline patient education about the importance of medication adherence, recommend changes to DOAC therapy, and provide additional assistance with medication access and affordability, similar to what has been done in our DOAC ambulatory clinic. Various models for centralized DOAC management have been reported, ranging from the traditional anticoagulation clinic models where patients are seen in clinic or through telephone encounters on a regular interval of 3 to 6 months to a population health model that leverages technology to identify patients who require intervention 12,13. Our management plan is more of a hybrid approach that provides a more traditional model for the first 6 months and then stratifies patients on the basis of the potential need for a dose adjustment to determine the subsequent follow-up intervals.…”