Experiences Encountered While Managing DOACs at Desert Oasis - PowerPoint PPT Presentation

Experiences Encountered While Managing DOACs at Desert Oasis Healthcare Robert Mao, PharmD Clinical Pharmacist Palm Springs, CA

Disclosures • I have accepted lunches and dinners from all the DOAC drug companies

30,000 seniors Desert Oasis Healthcare (DOHC) • • 30,000 commercial operates as an integrated Managed • 7,000 ACO patients Healthcare Organization. • Largest independent practice • Pharmacist Managed Enrollment associate and includes one of the first Clinic full service medical facilities in the Diabetes 825 Coachella Valley and the High Desert. CAD 296 Pharmacists in Population Health and • HepC 59 Prescription Management (PHARxM) operate ambulatory care clinics Anticoagulation 3,300 under established collaborative COPD 519 practice agreements with physicians. Refill Program 16,730

Population Health and Prescription Management (PHAR x M) • 25 Pharmacists including management • 3 PGY1 Pharmacy Residents • 17 Pharmacy Technicians • 8 Support Staff • Mon to Fri 8AM to 5PM but 24/7 on-call coverage for urgent issues

Our Anticoagulation Clinic • Manage 3,300 anticoagulation patients in Central and Southern California • 4 FTE pharmacists, 4 FTE technicians • Telephonic based from start to finish • Labs done at Quest/Labcorp • Monitoring DOACs since early 2015 • Other providers determine start/stop anticoagulation and hold duration for procedures but we can consult and provide suggestions!

Clinic Workflow 1. DOAC patient encountered 2. Pharmacist reviews patient records 3. Enrollment call by highly trained pharmacy technician 4. Follow up phone call done by technician at initiation, 2 weeks, 3-6 months Pharmacist reviews call – 5. As needed Review any hospital, urgent care, ER, or SNF visit – Remind physician to re-evaluate DVT/PE duration of – therapy

Phone Follow Up Call 1. Confirm which DOAC patient is taking 2. What dose is patient taking? Are they taking it as prescribed? Missed doses? 3. Any bleeding/bruising or (if Pradaxa) upset stomach? (ie: black stools/blood in urine/bleeding in gum or nose, unusual bruising) 4. Any cost issues/further refills 5. Any changes in medications or health/illness? 6. Does patient have CHF? If yes, please use questions below 1. Are you having any shortness of breath? 2. Are you having any unusual swelling? 3. Have you had any weight gain? 4. Have you had any changes to your diet? 5. Task back to pharm D to assess

Phone Follow Up Call 7. Any planned procedures? 8. Check Nextgen (EHR) to see if labs within last 3 months. Update in permanent box in DAWN 9. Patient to have labs at 2 weeks and then every 6 months 10. If no labs ask patient to go to lab (put date in permanent box) and send lab order 11. Remind patient to call us w/any bruising/bleeding, change in meds or health 12. Fill out questionnaire with new lab date 13. Task PharmD to review

Problem 1: Low Patient Volume • Losing warfarin patients at a rate greater than getting replaced by referrals • Not enough DOAC referrals DOAC Warfarin

Solution 1: Low Patient Volume • Warfarin: Enrollment by provider/hospital referral • DOAC: Blanket enrollment of anyone using it. No referral needed. • Allows for gradual enrollment vs overnight • DOACs represent 15% of our patients and rising. • Total anticoagulation patients are comparable to previous years numbers. • We have not yet captured all the patients using DOACs.

Problem 2: Demonstrating Value “Why are you drawing labs on my DOAC patients?” - Physician “My doctor manages me while I am taking Savaysa? Why do I need you?” -Patient

Solution 2: Demonstrating Value True or False: DOAC patients need regular monitoring. False . DOACs don’t need monitoring of therapeutic levels like warfarin. True . As a high risk medication, DOACs need careful monitoring of proper use, to ensure patients are on the proper dose, and have uninterrupted access. Nurses/pharmacists/etc. are well positioned to manage these patients.

“CAASE” for DOACs Self reported by patient Proper indication Pharmacy utilization database Dose adjustment based on labs, concomitant medications, etc. Bleeding/bruising Cost, is it affordable? TIA/Stroke/DVT/PE/MI Lowest Tier? Prior authorization

Solution 2: Demonstrating Value Demonstrating value to the patient Free service – Minimal phone calls – We monitor labs and inform their PCP – Explore other options if cost is a problem – Samples – Patient must opt out!

Problem 3: Interfacing Labs “I did the CBC and CMP you told me to do last week, what are my results?” –Patient • Patients would go to the lab, unscheduled, and we would not know.

Solution 3: Interfacing Labs Warfarin: “Go to lab on Sept. 15” DOAC: “Go to lab sometime this week” • Labs flagged daily in our electronic health record (NextGen) based on ordering provider. • Manually input into DAWN • Use Questionnaire (for phone call and labs) • Use Reminders tab (for Prior Authorization expiration, follow up after IC/hospital, etc.)

Problem 4: Cost Issues “The doctor at the hospital says I need to be on Pradaxa but it’s too expensive” –Patient “I’m in the donut hole, I can’t afford Xarelto anymore.” –Patient

Solution 4: Cost Issues • Why is it expensive? – Prior Authorization needed? – Improper dosing? Ex. Xarelto 10mg take 2 tablets by mouth daily with food? – Not covered by plan? • Compare against drug plan formularies. Is it the lowest Tier DOAC? Tier reduction?

Solution 4: Cost Issues 1. Free month supply for everyone 2. If commercial insurance, monthly co-pay card 3. Low income subsidy 4. Manufacturer patient assistance program 5. Samples – Align with drug representatives. How long do you provide samples for? 6. Switch to warfarin

Problem 5: Difficult Cases • Afib patient on Eliquis for a new DVT. 90 years old, weight = 50kg. Plan to start at 10mg PO q12hr x1 week, then 5mg PO q12hr. At what point do you lower to 2.5mg PO q12hr? What if patient has a bleed 3 days into therapy? Or 3 weeks into therapy? • Dialysis patient refusing to be on warfarin. Labile INRs with INR >10 drawn at dialysis. Off label Xarelto, Eliquis?

Solution 5: Difficult Cases • Your license, your liability • Doing nothing can be seen as negligence • Patient safety at stake • Who do you call? Call Cardiology (or PCP)

Solution 5: Difficult Cases • We are aligned with an outpatient Cardiology Clinic • Dr. Perlowski and cardiology trained NP Valerie Madaffari, Donald Gardenier, Lynn Fontana. Available Mon to Fri • On call physicians available after hours • Alternatives: Urgent Care Physician

Future Endeavors • Peri-procedural management of anticoagulation, without physician buy-in. Still seeing DOAC hold times of 5-7 days • Ability to address starting/stopping aspirin • Further streamline DOAC process • CA law SB 493 – Pharmacist provider status, order and interpret labs – Ability to order and make clinical decisions based on Ultrasounds, CT exams – Ordering and interpreting hypercoagulable workup

References 1. Shore, S., Ho, P. M., Lambert-Kerzner, A., Glorioso, T. J., Carey, E. P., Cunningham, F., Turakhia, M. P. (2015). Site-Level Variation in and Practices Associated With Dabigatran Adherence. Jama, 313(14), 1443. doi:10.1001/jama.2015.2761 2. The benefit of integrating pharmacists into patient care teams. (2015, April 23). Academy of Managed Care Pharmacy. Retrieved September 07, 2017, from http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/benefit- integrating-pharmacists-patient-care-teams 3. Peris, Russell. (August 2017). Email communication. 4. Barnes, G. D., Nallamothu, B. K., Sales, A. E., & Froehlich, J. B. (2016). Reimagining Anticoagulation Clinics in the Era of Direct Oral Anticoagulants. Circulation: Cardiovascular Quality and Outcomes, 9(2), 182-185. doi:10.1161/circoutcomes.115.002366 http://circoutcomes.ahajournals.org/content/9/2/182.short

Questions? Special thanks to the DOHC Anticoagulation team and Management Lindsey Valenzuela PharmD BCACP, Jade Le PharmD BCACP, Jan Wier PharmD, Shereen Patel, Megan Nguyen PharmD, and our wonderful technicians and support staff