1. Anticoagulation Clinic as Resident Teacher Gregory Raglow, MD Medical Director Jack Stuart, MD PGYII Michael Sty, MD PGYII Banner Good Samaritan FP Residency

2. Objectives Rationale and Set-up Demonstration of CoumaCare Software program Cases to teach: –Warfarin management –Chronic Disease management principles –Practice Innovation –Practice Based Learning and Improvement QA Project findings Resources for initiating this at your program

3. Objectives Oh, and show off our beautiful state

4. Rationale JAMA article documenting improved care Support of Nursing and Practice Management Resident Champion Team approach Opportunity to demonstrate practice innovation (FOFM)

5. Clinic Set-up Group visit (not mandatory) Referral form Principles –Maintain PCP relationship –Dosing adjustment only –Advise for procedures Algorithm Computer-based tracking Workflow

6. Group visit More time to teach –Why you’re on warfarin, benefits, risks, side effects –Effects of diet, other drugs –How clinic works PowerPoint presentation Time for questions Billed as 99213 Templated visit form

7. Invitation Letter

8. Visit Template

9. Diet Guidelines

10. Medication Guidelines Inform clinic personnel when meds change Always ask doctor if warfarin is affected when meds added May need closer monitoring

11. Procedures Schedule appointment 2 weeks in advance to discuss warfarin therapy Often we have to discuss with consultants Familiarity with guidelines varies

12. Referral form for clinicians Agreement about management principles Gather data about patient

13. Principles PCP relationship maintained Clinic personnel can serve as resource for decisions Clinic manages dosing to achieve goal INR set by PCP Pts advised to see PCP prior to procedures ACCP Guidelines and Algorithm

14. Workflow Draws on Tuesdays (standing orders) Weekly dosing Single tablet strength (usually 5 mg) Review labs the next day Nurse manager calls patient Algorithm Abnormals

15. Workflow Nurse Manager Physician Lab Tech

16. Computer tracking system

17. Algorithm

18. Case 1 High

19. Humphrey Peak 67 y.o. Male with AF, HTN INR = 3.3 Target 2.0-3.0 Current dose 5 mg/day –(35 mg/wk) Previous INRs 2.8, 2.5 What to do?

22. Marginal high Marginal if INR <0.5 off target Wait until 2 of 3 are off before changing dose Avoids chasing your tail

24. Marginal high 2 of 3 marginally high Adjust weekly dose based on chart

27. Dosage adjustment DaySunMonTueWedThuFriSat Tablet Size 5555555 Number1111111 New Number 111111/2 Weekly dose 35  30 mg

28. Case 2 Higher and higher

29. Ima Bleedin 55 yo F 3 months S/P DVT INR = 7.8 Weekly dose 30 What to do?

31. Anticoagulant Questions

32. Ima Bleedin Pt was on ABX 2 days left Bleeding Gums

35. ACCP Guidelines for High INR

36. ACCP Guidelines Describes strategies for high INR Based on INR value and presence of bleeding Hold Warfarin Give Vit K if bleeding or hi risk Green Tea effective

37. Case 3 ‘Twas the Night before Christmas… Nurse Kim knocks on my door

38. Rudy Rednose 37 yo female, Hx DVT INR of 8.2 Unable to find patient using all numbers What to do?

39. Rudy Rednose Returned Monday after holiday C/o epistaxis Held dose, added green tea Hmmm, can we prevent this?

40. Residents strategized Need all contact numbers Need cell phones INSTRUCTED PTS TO CALL IF NO CONTACT W/IN 48 hrs of lab draw Called all patients on list Added this to Group visit topics

41. Competencies Practice-based Learning and Improvement Systems-based practice

42. Case 4 And it goes on and on and on and on….

43. Ruth Sixtysix Received INR of 4.2 Reviewed chart 33 yo female Hx DVT after leg Fx with casting 18 Months Ago

44. Ruth Sixtysix No other risk factors ACCP Guidelines on length of therapy Should have stopped

45. What went wrong? PCP had determined length of therapy No stop date entered in computer

46. Strategies Reviewed all computer pt records to see if other pts need a stop date If unclear, then sent letter to PCPs and followed up on data

47. Competencies Another example of Practice-based Learning and improvement Access to computerized data is example of practice innovation Use of IT as promoted by FOFM Group visits Chronic Disease Management

48. Case 5 Up and down

49. Grant Canyon

50. Narrow Therapeutic Window

51. Tighter control Use of Coumadin Brand

52. Computer benefits Graphic data easier to assess List of names readily available On server, so accessible from many locations

53. Case 6 Dental Procedure

54. Call from dentist What to do about warfarin patient? Many specialists uncomfortable Need help and information Anticoag clinic personnel serve as resource

55. Other Procedures GI procedures Orthopedic Surgery Other surgery

56. ACCP Guidelines

57. ACCP Guidelines for anticoagulation during procedures

58. Anticoagulation Clinic: A Residents Perspective

59. Creation of the Coumadin Clinic Project started by Dr. Lee to improve practice management. Patients recruited through PCP referral, invitation of patients known to be on Coumadin, review of billing codes Design modified based on a Coumadin Clinic established in the Internal Medicine Department

60. Review of Evidence 1 “Comparing the Quality of Oral Anticoagulant Management by Anticoagulation Clinics and by Family Physicians: a RCT” Wilson, et al. CMAJ 2003;169(4): 293-298. Primary Outcome: proportion of time INR in an expanded therapeutic range Secondary Outcome: rates of thromboembolic and hemorrhagic events

62. Review of Evidence 1 Significant benefit of time spent in expanded therapeutic window with AC Management (82% vs. 76%) Fewer patients with INR 5.0 Less blood draws with AC care Overall patient satisfaction higher.

63. Review of Evidence 2 Am J Med. 2002; 113:42-51. Randomized trial involving patients 65 years and older with afib. Compared proportion of time in a therapeutic window with baseline management against anticoagulation clinic management.

64. Review of Evidence 2 No significant improvement time spent inside a therapeutic window. Control group (baseline: 47.7% follow up: 55.6%) Intervention group (baseline: 49.1% follow up: 52.3%) Event rates were not statistically significant between groups.

65. Arch Inern Med. 1998; 158: 1641- 1647 Review of Evidence 3 “Comparison of an Anticoagulation Clinic with Usual Medical Care” Chiquette et al –Compared “UMC” to “AC” –Cohort study –Newly anticoagulated patients –145 in UMC –183 in AC

66. Review of Evidence 3 Lower range –Fewer INR’s >5 (7% vs 14.7%) –More time in range (40% vs 37%) Higher range –More INR’s in range (50% vs 35%) –Fewer INR’s <2 (13% vs 23.8%) Fewer significant complications Savings of $162,058 per 100 patient years

67. Effective Clinical Practice. 2000 Jul-Aug; 3 (4): 179-180 Review of Evidence 4 “Complications of Warfarin Therapy: causes, costs, and the role of anticoagulation clinic” Hamby et al –Cohort study –306 patients followed –278 by VA AC, 28 by VA physicians –Events reviewed –Determined if preventable Bleeding (INR >5) Thrombosis (INR <2)

68. Review of Evidence 4 12 Total events occurred 8 not enrolled in AC Relative Risk 20 (95% CI, 6.4 to 61.8) An estimated $2300 per patient in costs for complications

69. 7 th ACCP Conference Guidelines

70. Management should be done in a systematic and coordinated fashion. Essential features of management include: –patient education –systematic INR testing –tracking of data –adequate follow up –appropriate communication with patients regarding dosing decisions

71. 7 th ACCP Conference Guidelines Bottom Line: No specific recommendation exists as to the need for establishment of a AMS. More data is needed.

72. QA Study—How are we doing? Informal study performed at GSRMC FPC Compared results before and after the start of the warfarin clinic Outcome measures –INR values in and out of range –Months in therapeutic range, out of range or not measured

73. Demographics Anticoagulation Clinic –32 females, 20 males –12 atrial fibrillation –4 CVA/Small vessel disease –2 Lupus anticoagulant –9 Pulmonary embolism –5 Mechanical heart valves –4 multiple –5 other

74. Demographics Usual Care –15 females, 17 males –10 atrial fibrillation –6 DVT –5 Pulmonary embolism –5 Mechanical heart valves –4 multiple –2 other

75. QA Study—How are we doing? INR Percentages –In therapeutic range –Marginal range (+/- 0.5) –Out of range –Months without INR values

76. QA Study—How are we doing? How did we do before?

77. QA Study—How are we doing?

78. Results

79. Critical events Before2 After start of Anticoag clinic0

80. Advantages of AC Improved patient education, tracking of results, and communication Improved patient continuity and follow up in a system with high physician turnover and limited physician experience Decreased adverse events

81. Advantages of AC Improved resident education –Intern curriculum –Noon conference curriculum –PCP involvement in decision making Platform for teaching practice management systems

82. Future Directions In-office testing Charge for some of the work

83. Point-of-Care Anticoagulation Devices Provide an INR result within 3 minutes of administering a drop of whole blood. Advantage: convenient, possible increased compliance, greater time spent in the therapeutic window, quicker lab return, billing Disadvantage: proper selection of patients, cost ($1200- 1500 for machine; $6-10 for cuvette)

84. Point-of-Care Anticoagulation Devices Am J Cardiovasc Drugs 2001; 1(4): 245-251. Reviewed benefits and implications for clinical practice Most studies show only modest benefit in terms of time in therapeutic window. One study demonstrates decreased thromboembolic and bleeding events over a 2 year period. (13.5 vs. 9.5%)

85. Anticoagulation Devices: Candidates 1.Require long term or life long therapy 2.Have no functional impairments 3.Appropriate cognitive abilities and willingness to manage own healthcare 4.Have appropriate funds or insurance

86. Anticoagulation Devices: Billing Point-of-Care testing may allow billing of a 99211 visit at our facility Obtain brief history and physical exam if needed. MDM based on INR value. Lab assessment of PT/INR (CPT: 85610) Long-term management of oral anticoagulants (V58.61)

87. Main Points

88. Anticoag clinics Result in improved care Can be used to teach important competencies Create a self-learning and motivating environment Practice innovation

89. Discussion

90. Resources All materials Tracking software ACCP Guidelines Algorithm Templates PowerPoint presentations