May Mak , Pharm.D . , CDE , BCGP Ass is tant Professor o f Pharmacy

USC School o f Pharmacy Fa l l 2017

BestPracticewithAnticoagulantsto

DecreaseReadmissions

Disclosure

Idonothaverelevant2inancialrelationshipswithcommercialinterests

(Iwillbespeakingfavorablyofwhatpharmacistscando

toreducerateofhospitalization/readmissions)

Objectives

�  Describeclinicalscenariosleadingtoactualorpotentialhospitalreadmissionsinpatientsreceivinganticoagulants

�  Provideupdatesonusageandadverseeventsassociatedwithoralanticoagulants,includingwarfarinanddirectoralanticoagulants(DOACs)

�  Recommendstrategiestopreventoccurrenceofadverseeventsassociatedwiththeuseofanticoagulants,leadingtofewerreadmissions

Questions

� WhatpercentageofERvisitsorhospitalreadmissionsisassociatedwiththeuseofanticoagulantsatyourinstitution?

�  Basedontheabove,whatareassociatedriskfactorsthatarepreventable?

�  Afterthispresentation,whatspeci2icinterventionswillyouconsiderimplementingtoreducereadmissionsassociatedwiththeuseofanticoagulants?

PrevalenceofReadmissions

•  1in5Medicarepatients(~2.6million)annuallyarereadmittedwithin30daysofdischarge

•  Translatesto$26billioncosttothehealthcaresystem.•  CosttoMedicareforpotentiallypreventable30-dayreadmissions:$12billion,preventablereadmissions~27%

•  Strongassociationswith:•  EDdecisionmaking•  Failuretorelayimportantinformationtooutpatientproviders•  Dischargingpatientstoosoon•  Lackofgoalsofcarediscussionswithpatientsre:seriousillnesses•  Interventionsnotprovidedduringinitialhospitalization

AHRQTrendsinHospitalReadmissions2009-2013

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1.HighRiskDiagnoses 2.HighRiskMedications

�  HeartFailure�  AcuteMI�  AdvancedCOPD�  Communityacquiredpneumonia�  GIbleed�  Diabetes�  Cancer�  >6chronicconditions

�  Antibiotics�  Glucocorticoids�  Anticoagulants�  Narcotics�  Hypoglycemicagents�  Antiepilepticmedications�  Antipsychotics�  Antidepressants�  Polypharmacy

RiskFactorsforReadmissions

3.DemographicFactors�Prioradmissionwithinlast6-12mo�Blackrace�Lowhealthliteracy�Reducedsocialnetworkindicators�Lowersocioeconomicstatus �D/CAMA

AssociationBetweenAnticoagulationTherapyandRisksofMortalityandReadmission

Hernandezetal.CircCardiovascQual

Outcomes2014;7:670-679

Mortality

Stroke

HeartFailure

OtherCVEvents

Bleeding

AnticoagulantsAdverseEvents

ISMP/FAERS2016Reports CDCStudy:ERVisits2013-4

•  21,996severeinjuriesintheU.S.–  3,018deaths–  17,218hemorrhages(8,495GIbleed)–  835renalimpairmentorfailure

•  Rivaroxaban(68.4%)>Apixaban(14.3%)>Dabigatran(8.8%)>Warfarin(8%)>Edoxaban(0.5%)

•  AnticoagulantsaccountedformoreEDvisitsthanopioids,antibiotics,andantidiabetics.

•  NationalElectronicInjurySurveillanceSystem-CooperativeADEsSurveillanceSystem

•  Anticoagulantsaccountedfor17.6%ofallEDvisitsfordrugadverseevents.

•  Hospitalizationoccurredfor:–  63.8%receivingdabigatran–  50.4%receivingrivaroxaban–  48.5%receivingwarfarin–  vs.24.6%takingtherapeuticopioids,7.1%

antibiotics

•  Anticoagulantdruginjuryrelatedvisitsincrfrom2005/6to2013/4>2x

CostAnalysisperADREvent

�  Mosthospitalizationexpenditurewereattributedtonursingandpharmacycost.

�  ReducinganticoagulationADR’shavethepotentialtodecreasehospitalizationcostsandimprovepatientsafety.

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Idarucizumab$3,500

ProthrombinComplexConcentrate$5,000

RiskFactorsforReadmissionsinPatientsReceivingAnticoagulants

•  Age•  Lackofeducationaboutanticoagulantsandlackoffollowup•  Medicalconditions

•  Alcohol•  Heartfailure•  Severeinfections•  Hepaticimpairment•  Renalimpairment

•  Inappropriatedosingoradministration•  InadequateINRlevelsforhighthromboticconditions•  ExcessiveINRlevels•  Lackofappropriatebridging•  Nonfamiliaritywithnewanticoagulants

•  Drug-druginteractions•  Additiveantiplateleteffects•  MetabolicCYPandP-gpinteractions

Case1:ReadmittedafterCATH

�  77yowithhxNSTEMI(2013),CADs/pDESx2(2015),severeMS,A2ib�  Warfarinregimen:4-6mgdaily(2-3tabsof2mgwarfarin)�  Hospitalizedon7/5/17forcardiacCATH�  DC7/7/17withwarfarin6mgtablets#90,sig:1tabdaily,INR1.82�  Anticoagulationf/uon7/17/17:INR7.32.Clinicinstructions:holdwarfarinx4days.�  7/21/17FUP,INR2.9,warfarinresumed:4mgdaily(2x2mgtabsdaily).Note:Medrecperformedw/outfullaccuracyd/tpatientnotbringingmedicationbottles;acknowledgedhavingsupplyof2mgtabsathome.

�  7/28/17FUP,INR>12!Patientagaindidnotbringmedicationbottles,onlymedorganizer.Whenaskedtoidentifytabletcolor,described6mgcolorstrength.Medorganizerhadboth2mgand6mgwarfarintabsmixedinthesamecompartment.

ContributingFactors NecessaryImprovement

1.  Poormedrec:admission,discharge,clinic

2.  ChangeinwarfarinmgRxnotcaughtbypharmacy

3.  DuplicateRxsnotcaughtbyclinic

1a.EducationonpillID,alwaysbringRxbottlestoallplannedvisits1b.Trainandretrainpersonnelperformingmedrec1c.Bettercaretransitions2a.PharmacytoraisealertlevelondispensingdifferentanticoagulantsordifferentmgRx2b.Prescriberstoordersamestrengthtabletorspecifyreasonfordifferentstrengths3a.Clinicproviderstakeextracautionduringphasesofcaretransitions3b.Repeateducationtoraisepatient’slevelofawareness;bettermethodsofassessingunderstanding3c.EmphasizeimportancetobringRxbottlestovisits

Multi-factorialFactorsfromRoot-CauseAnalysis-1

Case2:NearMiss

�  59yowithhxCADs/pstentx2(2014),HF,LVthrombus6/2017,NSTEMI7/2017,admittedtooutsidehospitals,dc’d7/2017

�  Originalwarfarin4mgRxfrom6/2017butpatientdidnottakeuntil4daysbeforeAnticoagulationServiceappointmenton8/20/2017

�  8/20/2017medrec:•  2bottlesofASA81mg(taking162mg/d)•  3bottlesofatorvastatin80mg+1bottleofatorvastatin40mg(taking260mg/d)•  2bottlesofclopidogrel75mg(taking150mg/d)•  2bottlesofspironolactone25mg(taking75mg/d)•  1bottleofwarfarin4mg(took4mgdailyxlast4days)

�  Labs:Hgb(12-14.6) Plt((160-360) SCr(0.5-1.0) eGFR K+(3.5-5)

6/20/17 14.8 112K 1.73 30 3.8

8/20/17 12.2 84K 2.17 24 5.0

ContributingFactors NecessaryImprovement

1.  Poormedrecuponadmission,discharge

2.  Poortransitionsbetween

hospitals

3.  Multiple“bloodthinners”putting

patientathighbleedrisk

4.  Renalimpairmentalsoincreasespotentialforreadmission

1a.EducationonpillIDandpurpose1b.Trainallonimprovingmedicationreconciliation2a.D/Csummariesprovidedandexplainedtopatient2b.D/Cmedicationeducationprovidedtopatientandcaretaker2c.Con2irmf/uappointments3a.Purposeofmedicationsexplainedandunderstoodbypatient.3b.Consequenceofsuboptimaltherapyshouldbedescribedtopatient3c.ProvideERprecautions4a.ProviderstobealertedtomonitorRxsthataffectkidneyfunction.4b.EHRalertstoprovidersandpharmacytomonitorandverifyorders

Multi-factorialFactorsfromRoot-CauseAnalysis-2

ReasonsforNon-adherencetoDischargeMedications

•  50%ofpatientscannotrecalldischargeorders;ofthese,70%likelytobereadmitted

•  Dischargedlate,unabletowaitormakeextrastoptopharmacy•  Lackofunderstandingofpurposeandimportanceofcontinuoustreatment(i.e..lowerhealthliteracy,lowercognitivefunction)

•  Fearofpotentialsideeffects•  ChangeindosingregimennotcommunicatedorexplainedatdischargeORexplainedbutnotunderstoodorrecalledbypatient

•  Healthplansnotcoveringthespeci2ictherapyprescribed•  Increasednumberofprescribedmedications•  Financialburden,unabletopayformedications

Case3:NearMiss

�  46yo15-yrhxofNVAF,warfarintherapymonitoredbyanticoagulationserviceuntilproviderswitchedfromwarfarintorivaroxabanFeb.2016

�  Losttoanticoagulationclinicf/u,novalidphonenumber.BrokeappointmentwithcardiologistAug.2016

�  Dec.2016:RTCtocardiologist,anticoagulationclinicwasconsultedwhetherrivaroxabancouldbeloweredfromstandarddoseof20mgdailyto15mgdailyduetogumbleeding

�  MedrecwithanticoagulationclinicDec.2016:•  Didnotadheretorivaroxabanafter1monthoftreatmentd/tgumbleeding•  Noanticoagulationtherapyforthepast9months

ContributingFactors NecessaryImprovement

1.  Lackofcommunicationregardingswitchofanticoagulants

2.  Misconceptionthatnewanticoagulants(DOACs)donotrequiremonitoring

3.  Patientnoteducatedregardingriskofnon-adherence

4.  Switchofproviders(betn2/2016and12/2016):nocontinuumofcare

5.  Pharmacydidnot2lagnof/ure2illofanticoagulants

6.  Potentialofinadequatedosagefromminorbleedingnotdirectlycausedfromnewagent

1.Improvecommunicationbetweenprescribersandanticoagulationservice

2.In-servicetoprescribersregardingproperdosageperrenalfunctionmonitoringforDOACs(ADRs,renalfunction,etc.)

3.Properpatienteducationregardingrisksandnecessarymonitoringforallanticoagulants,includingDOACs,atinitiationandcontinuous

4.ProvideEHRalertstoallproviderstomonitorpatientscloselyonallanticoagulants5.Pharmacytoputinautomonthlyalertsforpatientswhodonotre2illanticoagulantRxs

6.Providereducationtoavoidprescribingsuboptimaldosewithoutproperindications,suchaspoorrenalfunction(insomecasesw/DAPT)

Multi-factorialFactorsfromRoot-CauseAnalysis-3

SuccessfulCareTransitionComponents

•  MedicationReconciliation•  AnticoagulationManagement•  BedsideCounseling•  DischargeInstructions•  Follow-upCare

HospitalNationalPatientSafetyGoalsReconcilingMedications

ImpactofPharmacy-LedMedicationReconciliation

�  Observationalprospectivecohortstudyin2015ata531-bedhospitalx3m

•  Conclusion:medicationreconciliationpromotescostsavingsbasedonpotentialreventableADE;ensurespatientsafety

�  SystematicReviewandmeta-analysisin2016:•  19studies,15,525adultpatients•  Conclusion:pharmacy-ledmedicationreconciliationinterventionseffective

strategytoreducemedicationdiscrepancies;hadgreaterimpactwhenconductedatadmissionordischarge

PharmacyPracCce.2015;13(4):634 JClinPharmTher2016;41:128–144.

HospitalNationalPatientSafetyGoalsSafeUseofAnticoagulantTherapy

andDOACs

includingrenalfunc?onforDOACs

AnticoagulationManagement

�  Appropriateindications�  Patientspeci2icrecommendations:selecttherightagentandgiveappropriatedose

�  EHRalerts�  Quantitylimits�  Labmonitoringalerts�  Resourcesforsafemanagement(dzanddruginteractions)�  Applypharmacogeneticsprinciple

•  2C9andVKORC1mutationinpatientsaltersresponsetowarfarin•  MutationsingenesaffectingDOACsalsoidenti2ied•  2C19mutationforclopidogrellowersef2icacy•  2C19mutationforprasugrelincreasesriskbleed

DOACsinTransitions

Advantages Disadvantages

Rapidonsetofaction,noneedforbridgingFixeddosegivespredictableeffect,minimizeprescribingerrorLowpotentialforfoodinteractions(Lowerpotentialfordruginteractions)

PotentialfornotstartingorcontinuingtherapyuntilthenextFUPvisitRiskofstrokewithskippeddoses

StillneedtomonitorrenalfunctionandpotentialdruginteractionsNon-familiarityof2irstresponderstothenewagentsReversalagentspending

Uncertaintyofmanagingclinicalscenarios

WhataboutPatient’sResponsibilitiestoStayWellandLowerReadmissionRate?

(%) (days)

JofNursingAdministraCon2015;45(1):35-42

BedsideCounseling

Single-center,retrospectivecohortstudyconductedataCA462-bedhospital�  PharmacistdischargecounselingprogramimplementedinJuly2013�  Patientstargetedifhadtheseriskfactors:(1)concurrentuseof>5scheduled

medications,(2)ESRD,(3)pneumonia,(4)COPD,(5)diabetes,(6)CHF,(7)MI,(8)high-alertmedicationslikewarfarin

�  889patientsevaluated,488(55%)receivedcounselingfromapharmacist�  Readmissionrate30-daysafterhospitaldischarge,counseledvs.non-counseled

patients:11.3%v15%,(p=.009)orEDvisits:10.6%v.15%,(p=.005)

�  Otherbene2its:improvepatientoutcomes&satisfaction,reduceddelayinreceivingdischargemedications,identifying2inancialissuesupfront

Takehomepoints:

•  Targethighriskpatients(slide11)

•  DischargemedicationsneedtobeavailableforeffectiveteachingorlearningJHospAdm.2017;6(2):68-73

KeytoSuccessofaBedsideDischargeMedicationProgram

•  Hospitalleadershipandphysiciansupport•  Nursing,casemanagement,pharmacycollaboration•  Communicationofbene2itsofservicetopatientsearlyduringhospitalstay

•  Navigatorsaskeycommunicator,coordinator,andimplementationoftheprogram

•  Mustnotdelayorinterferewithwork2lowforpatientdischarges•  Mustbeeasyforpatientstoparticipate

DischargeInstructions6ElementsofaSuccessfulHospitalDischarge

•  Evaluation•  Ofneedssoonafteradmission•  Identifytreatmentandrecoverygoals

•  Discussion•  Patientadvocates,familymembers,caretakers•  Inter-professionalteamtoanticipateneeds

•  Planning•  Transitionsites,identifyreceivingprovidersandcareteams

•  Determining•  Needsvs.feasibility/coverage•  Beyondmedicalneeds•  Logistics

•  Referrals•  Startearlytosecurenecessaryfollow-ups

•  Arranging•  Makeappointmentsforfollow-upsandmonitoring

6ElementsofaSuccessfulHospitalDischarge.ProfessionalSkills,ProfessionalPatientAdvocateInstitutehttp://www.patientadvocatetraining.com/2011/10/12/6

Successful Care Transition Components •  Medication Reconciliation •  Anticoagulation Management •  Bedside Monitoring / Counseling •  Discharge Instructions •  Follow-up Care

Follow-upCareKey:ProviderCommunication

�  Communicationbreakdown-arootcauseofineffectivetransitionsofcare�  Careprovidersdonoteffectivelyorcompletelycommunicateimportant

informationamongthemselves,tothepatient,orcaregivers�  CenterforTransformingHealthcare’shand-offprojectfoundseveralrisk

factorsrelatingtocommunication:•  Expectationsdifferbetweensendersandreceiversofpatientsintransition•  Culturedoesnotpromotesuccessfulhand-off(e.g.,lackofteamworkandrespect)•  Inadequateamountoftimeprovidedforsuccessfulhand-off•  Lackofstandardizedproceduresinconductingsuccessfulhand-off,e.g.useofSBAR

(situation,background,assessment,recommendation)

�  Areasofimprovement:•  Standardizedhospitaldischargeprocess•  Educatedischargeteammembersre:potentialofanticoagulationmis-haps•  Ef2icientandtimelytransferofpatientdataandinformation•  Providinghigh-qualityinformationtothepost-dischargeacceptingprovider

hQps://www.jointcommission.org/assets/1/18/Hot_Topics_TransiCons_of_Care.pdf

AnticoagulationServiceasaTransitionTeam

•  Inpatientservices•  Educate•  Optimizetherapyselectionanddosing•  Facilitatepatient-centereddischargeprocess

•  Outpatientservices•  IncludeNOACsandantiplateletmanagementinadditiontowarfarin

•  Stewardshiponantithromboticservices•  Educate•  Communicate•  Involvepatientsandproviders

Questions

� WhatpercentageofERvisitsorhospitalreadmissionsisassociatedwiththeuseofanticoagulantsatyourinstitution?

�  Basedontheabove,whatareassociatedriskfactorsthatarepreventable?

�  Afterthispresentation,whatspeci2icinterventionswillyouconsiderimplementingtoreducereadmissionsassociatedwiththeuseofanticoagulants?

References•  Hospitaldischargeandreadmission.UpToDatewebsite,http://www.uptodate.com.UpdatedApr3,2017.AccessedSep17,2017.•  Readmissionstohospitalsbydiagnosis,AHRQStatisticalBrief,http://www.hcup-us.ahrq.gov/reports/statbriefs.Published2013.

AccessedSep30,2017.•  HernandezA,LiangL,FonarowG,etal.Associationsbetweenanticoagulationtherapyandrisksofmortalityandreadmissionamong

patientswithheartfailureandatrial2ibrillation.CircCardiovascQualOutcomes2014;7:670-9•  Oralanticoagulantdrug,InstituteforSafeMedicationPracticesQuarterWatch,http://www.ismp.org/QuarterWatch,2016Q4Annual

Report.•  PiazzaG,NguyenTN,CiosD,etal.Anticoagulation-associatedadversedrugevents.AmJMed2011;124(12):1136-1142.doi:10.1016/

j.amjmed.2011.06.009.•  UygungulE,AyrikC,NarciHetal.Determiningriskfactorsofbleedinginpatientsonwarfarintreatment.AdvHematol2014;369084.doi:

10.1155/2014/369084.Epub2014,Nov.9.•  UnroeK,PfeiffenbergerT,RiegelhauptS,etal.Inpatientmedicationreconciliationatadmissionanddischarge:aretrospectivecohortstudy

ofageandotherriskfactorsformedicationdiscrepancies.AmJGeriatrPharmacother20108(2):115-26•  Goal3:Improvethesafetyofusingmedications(anticoagulants,medicationreconciliation).NationalPatientSafetyGoals.

http://www.jointcommission.org/assets/1/6/NPSG-Chapter-HAP-Jan2017.pdf..hNp://www.jointcommission.org/assets/1/6/NPSG-Chapter-AHC-Jan2017.pdf.PublishedJan2017,AccessedSep30,2017.

•  SmithL,MosleyJ,LottS,etal.Impactofpharmacy-ledmedicationreconciliationonmedicationerrorsduringtransitioninthehospitalsetting.PharmacyPractice.2015;13(4):634.doi:10.18549/PharmPract.2015.04.634.

•  McKonnenA,McLachianA,BrienJ.Pharmacy-ledmedicationreconciliationprogrammesathospitaltransitions:asystematicreviewandmeta-analysis.JClinPharmTher2016;41(2):128-44

•  O’ConnorC,KiernanT,YanB.Thegeneticbasisofantiplateletandanticoagulanttherapy:Apharmacogeneticreviewofnewerantiplatelets(clopidogrel,prasugrelandticagrelor)andanticoagulants(dabigatran,rivaroxaban,apixaban,andedoxaban).ExpertOpinDrugMetabToxicol2017;13(7):725-39

•  StillKL,DavisAK,ChilipkoAA,JenkosolA,Norwood.DK.Evaluationofapharmacy-driveninpatientdischargecounselingservice:impacton30-dayreadmissionrates.ConsultPharm.2013;28(12):775-85

•  HeidbuchelH,VerhammeP,AlingsM,etal.EHRApracticalguideontheuseofneworalanticoagulantsinpatientswithnon-valvularatrial2ibrillation.Europace2015;17:1467-1507.

•  HowardM,LipshutzA,RoessB,etal.Identi2icationofriskfactorsforinappropriateandsuboptimalinitiationofdirectoralanticoagulants.JournalofThrombosisandThrombolysis.2016;43(2):149-156.doi:10.1007/s11239-016-1435-3.

•  TheBOOSTTools.ProjectBOOSTImplementationToolkit.http://www.hospitalmedicine.org.Updated2014,AccessedSep30,2017•  ProjectRED.http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html