Anticoagulation Forum Offers Guideline for Stewardship
The Anticoagulation Forum’s Core Elements of Anticoagulation Stewardship Programs offers a roadmap for institutions to practice stewardship at the system level and describes opportunities for pharmacists to help lead the way.
The guideline, which was released last fall, has seven core elements that focus on administrative leadership and commitment; professional accountability and expertise; multidisciplinary support; data management; implementation of sustainable, systematic care; transitions of care; and staff and patient education.
Pharmacists have long been engaged, as clinicians, in the day-to-day management of anticoagulation therapy. But they haven’t necessarily been performing what the guideline refers to as anticoagulation stewardship.
“The concept of stewardship is to make sure that we’re using the drug as optimally as possible. And in order to do that, we have to have somebody overseeing it from a programmatic point of view,” said Steve Meisel, system director of medication safety for M Health Fairview in Minneapolis.
“What the guidelines ... are talking about is organizational leadership,” said Meisel, who served on the committee that developed the document.
He said one important way pharmacists can provide such leadership is to develop institutional protocols for the prescribing and use of anticoagulation reversal agents, particularly those used to counteract direct oral anticoagulant (DOAC) drugs.
According to the guideline, common system-level deficiencies that can be managed through stewardship programs include the prescribing of DOACS or other anticoagulants despite contraindications and the use of empiric dose reductions for DOACs.
Anne Rose, anticoagulation stewardship pharmacist for UW Health in Madison, Wisconsin, called the guideline comprehensive and said she was pleased that it calls for system-level attention to the use of DOACs.
“We’ve historically just been focused on warfarin. And now that these newer direct oral anticoagulants are out, having our health systems look at gaps for those particular drug classes is key,” she said.
Rose said pharmacists can help their organization ensure that patients are started on the correct dosage of a DOAC. She said pharmacists can also ensure that these patients are appropriately monitored — something physicians may not be aware is needed when they prescribe a DOAC.
“We do know that we need to be checking renal function periodically, and we should still be touching base with our patients,” Rose said. “Pharmacists can definitely lead the way in monitoring for these newer drugs.”
The guideline lists more than three dozen examples of system-level deficiencies in anticoagulation management for stewardship programs to target. The deficiencies include problems related to the prescribing and use of anticoagulants, patient assessment, the management of adverse events, transitions in care, and other issues.
Meisel said there’s a leadership role for pharmacists in addressing “basically everything” on the deficiency list.
He especially urged organizations to include transitional care in their anticoagulation stewardship programs.
Transitional care lapses, he said, include starting a patient on warfarin during an inpatient stay and discovering, after the patient is readmitted for a bleeding event, that no one checked to ensure the patient made and kept essential follow-up appointments.
“That sort of stuff is real; it happens all the time. And so who is accountable to make sure that those transitions happen?” he asked.
Rose said UW Health launched its anticoagulation stewardship program in 2009. She said the stewardship team’s work includes the development of comprehensive guidelines, protocols, and education programs for pharmacists, nurses, and physicians.
“We really try to touch all those frontline groups so that we’re managing or caring for the patients in the same way,” she said.
Rose also works closely with the organization’s information technology department to incorporate anticoagulation tools into the electronic medical record system. And she gets feedback from her physician and nurse colleagues to develop documentation and to ensure that the tools fit into the staff’s workflow.
She said she’d like to see pharmacists leading stewardship initiatives that involve quality and safety metrics, such as reviewing past adverse events, spotting trends, and developing strategies to prevent future occurrences.
The guideline likewise emphasizes the importance of collecting, tracking, and analyzing data to guide system-level decisions about anticoagulant use.
Funding for the guideline’s development was provided by the Food and Drug Administration.
Visit ASHP’s Anticoagulation Resource Center for comprehensive information about anticoagulation management.
[This news story appears in the July 1, 2020, issue of AJHP.]