Involving anticoagulation clinics may help manage blood clot meds before a procedure

Last Updated: 2020-02-13

By Will Boggs MD

NEW YORK (Reuters Health) - Referral to an anticoagulation clinic, facilitated by a best-practice alert in the electronic medical record (EMR), is associated with improved preprocedure management of antithrombotic medication for patients undergoing gastrointestinal endoscopic procedures, researchers report.

"I hope that physician leaders see the need for coordinated care in the preoperative period," Dr. Geoffrey D. Barnes of the University of Michigan, in Ann Arbor, told Reuters Health by email. "And I hope that they see the value of expert pharmacists in the anticoagulation clinic who provide high-quality care through a systematic referral process."

Managing chronic antithrombotic medications before an elective procedure can be challenging, and often these antithrombotic medications are not managed in accordance with clinical trial evidence or guideline recommendations, thereby placing patients at risk for thrombotic or bleeding complications.

Dr. Barnes and colleagues developed a best-practice alert within the EMR that recommended referral to the anticoagulation clinic for outpatients currently taking long-term antithrombotic medication (other than aspirin) when an elective gastrointestinal endoscopy was ordered.

After implementation of the alert, two-thirds of patients using antithrombotic medications were referred to the anticoagulation clinic along with their endoscopy orders, the authors report in JAMA Network Open.

"The most interesting finding was how rapidly the anticoagulation-clinic referral was adopted by clinicians once the best-practice alert was activated," Dr. Barnes said.

Significantly fewer patients in the postimplementation phase (1/52, 1.9%) than in the preimplementation phase (8/50, 16.0%) required a same-day alteration or cancellation of their endoscopic procedure as a result of antithrombotic-medication mismanagement.

After implementation, more than half of pre-endoscopy antithrombotic management instructions were given by the anticoagulation clinic (52.8%), followed by cardiologists (8.3%) and primary-care clinicians (5.6%).

Patient satisfaction with communication about and coordination of pre-endoscopy antithrombotic medications was high before (84.7%) and after (95.3%) implementation of the program, as was satisfaction with finding information about pre-endoscopy medication management (90.3% vs. 95.2%, respectively).

After implementation of the best-practice alert, significantly more clinicians agreed that the anticoagulation clinic provided assistance with determining the need for periprocedural bridging anticoagulation, recommended an agent for periprocedural bridging, and prescribed any bridging anticoagulant medication.

Nearly half believed that the anticoagulation clinic should make preprocedure antithrombotic-medication decisions after implementation of the best-practice alert, compared to less than a quarter before implementation.

"When an alert and referral process are well-designed, the redesigned care process can facilitate high-quality preoperative care for patients that improves patient and provider satisfaction," Dr. Barnes said.

"The main barrier to implementation was gaining buy-in from all the key stakeholders, including the necessary funding to support an extra pharmacist in the anticoagulation clinic to manage these patients," he said. "We also had to update or develop new institutional policies around preprocedure management of both anticoagulant and antiplatelet medications for the pharmacists to follow when helping to coordinate management of these patients."

SOURCE: https://bit.ly/2SGovn5 JAMA Network Open, online February 5, 2020.