National Institutefor Public Healthand the Environment

Cooperation in oral anticoagulant therapyneeds and barriers to improve

H. Drewes, M. Lambooij, C. Baan, B. Meijboom, G. Westert

National Institutefor Public Healthand the Environment

Oral anticoagulant therapy (OAT)

OAT reduce the risk of thrombosis

• Challenge: balance the risk between haemoraghe and thrombosis

• Balance influenced by many factors - e.g. co-medication, fever, food intake, doses advices

• Balance influenced by many health care professionals

Cooperation needed

• No. of patients in NL: 350.000

• 25% of avoidable hospitalizations related to OAT

National Institutefor Public Healthand the Environment

Anticoagulant clinics (AC)

• In Netherlands 59 anticoagulant clinics (ACs): monitoring patients and advice on medication use

• ACs provide better patient outcomes than routine medical care

However:

• Substantial differences in patient outcomes between ACs

• Differences in cooperation between ACs

- e.g. multidisciplinary protocols, structural meetings etc.

National Institutefor Public Healthand the Environment

Research questions

To identify the bottlenecks for cooperation

To identify facilitators/solutions to improve cooperation

To identify barriers for improvement the cooperation

National Institutefor Public Healthand the Environment

Methods

• Data

- 23 specialised anticoagulant clinics (AC)

- selective purposive sampling based on 3 characteristics:• the number of patients

• the organisation structure

• quality of care considering the patient outcomes

- 68 semi-structured interviews

National Institutefor Public Healthand the Environment

Methods

Data analysis

- Fully transcriped interviews open coded by two authors

- data structured with Chronic Care Model

National Institutefor Public Healthand the Environment

Experienced bottlenecks

• Lack of knowledge:Although a patient was stable with 6 tablets a day, he was

discharged with a doses of 4, 2, 2, for the following three days. [..]You could say, ask the patient what he usually used.

• Lack of consensus between professionals

We don’t agree with the policy of one of our hospitals, but couldn’t convince them. We have to follow their advice; otherwise patients are send home without an operation.

• Limited information exchangeReally, it is sometime a struggle to get the information about a

hospital admission.

National Institutefor Public Healthand the Environment

Experienced bottlenecks

Bottlenecks leads to:

• - Suboptimal OAT

• - Inefficacy due to time-consuming effort to correct mistakes

National Institutefor Public Healthand the Environment

Preferred initiatives

Facilitators # Solutions # Health care organization 29 9 Easy informal coordination 19 2 United professionals 1 Quality management 4 2 Accreditation 1 External Stimuli 3 3 Leadership 2 Delivery system (re)design 5 24 Clinical information system 9 13 Decision support 23 90 Education 20 31 Meetings 2 15 Protocols/ agreements 3 32

1

National Institutefor Public Healthand the Environment

Major Experienced barriers

• Lack of motivation

- professionals not motivated to learn from ACs (no knowledge)

- don’t accept their view (no consensus)

- are not motivated to inform the ACs (no information).

Lack of time

• Lack of resources/ materials

National Institutefor Public Healthand the Environment

Conclusions

• Bottlenecks of coordination are information exchange, lack of knowledge, lack of consensus

• Decision support is prerequisite for the succes of AC management as it improves knowledge

• Crucial to succesfully implement decision support seems to be informal coordination/contact