Incorporation of DAWN AC DOAC Modules Into Practice Peter Collins, PharmD, RPh Advanced Practice Clinical Pharmacist Anticoagulation Management Service
Objectives � Introduce DAWN AC DOAC modules and current work flow � Discuss initial changes made prior to launch of DOAC pilot program � Summarize post-launch issues encountered and how resolution was achieved � Plan for future changes going forward to optimize functionality
DAWN AC DOAC Modules � Questionnaire format (Candidate, Follow Up) � Supported diagnoses: – Pulmonary Embolism (Provoked, Non-Provoked, Recurrent) – Deep Vein Thrombosis (Provoked, Non-Provoked, Recurrent) – Non-Valvular Atrial Fibrillation (NVAF) – Orthopedic Surgery VTE Prophlyaxis • Total Hip Replacement • Total Knee Replacement � Supported DOAC Agents: – Rivaroxaban – Dabigatran – Apixaban – Edoxaban
Managed Care Plan
Managed Care Plan
Candidate Questionnaires � Documents patient characteristics (age, gender, ect.) and indication for anticoagulant therapy � Aids with transition from previous anticoagulant (if applicable) � Assesses: – Renal Function – Drug-Drug Interactions – Contraindications to DOAC therapy � Provides dosing regimens with additional advice
Candidate Questionnaire: Transition From Previous Anticoagulant
Candidate Questionnaire: Renal Function Assessment
Candidate Questionnaire: Drug-Drug Interactions
Candidate Questionnaire: Contraindications To Anticoagulant Therapy
Candidate Questionnaire: Dosing Advice
Managed Care Plan
Managed Care Plan
Managed Care Plan
Managed Care Plan
Follow Up Questionnaires � Aids with documentation of induction dose to maintenance dose transition (VTE indications only) � Assesses: – Adherence / compliance – Adverse events – Renal Function – Drug-Drug Interactions – Therapy Contraindications � Provides dosing regimens with additional advice
Follow Up Questionnaires Induction Dose To Maintenance Dose Transition Adherence / Compliance
Follow Up Questionnaires Adverse Events
Initial Changes Made Prior To DOAC Clinic Launch � Updating Dosing Regimens for DOAC Agents � Integrate DAWN AC and EPIC � Add “Labs” Questionnaire � Update Clinical References
Initial Changes Made Prior To DOAC Clinic Launch � Updating Dosing Regimens for DOAC Agents � Integrate DAWN AC and EPIC � Add “Labs” Questionnaire � Update Clinical References
Updating DOAC Dosing Regimens � Inconsistencies existed between preloaded European dosing regimens from DAWN AC and regimens used in the United States � Examples include: – Dabigatran 110mg twice daily for atrial fibrillation (not approved US regimen) – Apixaban use in patients with creatinine clearance < 30 mL/min – Rivaroxaban 10mg daily for VTE prevention (EINSTEIN-CHOICE)
Updating DOAC Dosing Regimens
Initial Changes Made Prior To DOAC Clinic Launch � Updating Dosing Regimens for DOAC Agents � Integrate DAWN AC and EPIC � Add “Labs” Questionnaire � Update Clinical References
Integrate DAWN AC and EPIC � Information from DAWN AC is exported and displayed in EPIC via the AMS Icon � DOAC AMS icon includes: – Patient Information • Name, MRN • Referring Physician • AMS Clinician and contact information – Clinical Information • DOAC agent and regimen • Indication for anticoagulation • Treatment Duration and start date • Laboratory Values • Last note entered in DOAC questionnaire
EPIC AMS Icon (Warfarin)
EPIC AMS Icon (DOAC)
Initial Changes Made Prior To DOAC Clinic Launch � Updating Dosing Regimens for DOAC Agents � Integrate DAWN AC and EPIC � Add “Labs” Questionnaire � Update Clinical References
Add “Labs” Questionnaire � Easily allows for documentation within DAWN of DOAC-related laboratory values � Must be manually entered (no EPIC interface at this time) � Laboratory values are exported to AMS icon in EPIC
Initial Changes Made Prior To DOAC Clinic Launch � Updating Dosing Regimens for DOAC Agents � Integrate DAWN AC and EPIC � Add “Labs” Questionnaire � Update Clinical References
Update Clinical References � DOAC questionnaires contain links to clinical references throughout � European guidelines were replaced with institutional drug administration guidelines and US package inserts � Hyperlinks can be edited via DrugCoURL function in DAWN AC System Menu
Post-DOAC Clinic Launch Changes � Increase documentation functionality � Patients with diagnoses outside of preloaded indication list � Hard stop contraindications
Post-DOAC Clinic Launch Changes � Increase documentation functionality � Patients with diagnoses outside of preloaded indication list � Hard stop contraindications
Increased Documentation Functionality � Focused on documentation surrounding patient interactions and hospital admissions � “Notes” questionnaire was created with two templates for both types of encounters
“Notes” Questionnaire
Post-DOAC Clinic Launch Changes � Increase documentation functionality � Patients with diagnoses outside of preloaded indication list � Hard stop contraindications
Patients With Unsupported Treatment Indications � Refers to DOAC patients that do not fall under the preloaded diagnoses � Example: history of CVA without documented atrial fibrillation � Temporary Solution: – Atrial Fibrillation (NVAF) is selected as diagnosis but true reason for anticoagulation therapy is noted in patient’s profile � Leads to incorrect diagnoses displayed in EPIC AMS icon
Post-DOAC Clinic Launch Changes � Increase documentation functionality � Patients with diagnoses outside of preloaded indication list � Hard stop contraindications
Hard Stop Contraindications � Patient specific clinical decisions may lead to using regimens that are technically contraindicated � Workarounds are required to allow the DAWN AC system to process and complete questionnaires
Hard Stop Contraindications � Apixaban use in patients with renal dysfunction: � Solution: leave creatinine clearance blank and document in the notes section that patient is on dialysis
Hard Stop Contraindications � DOAC use in patients with bioprosthetic heart valves: � Solution: Document in the Notes section that patient has heart valve, but do not select “Prosthetic Heart Valve” under “Contraindications”
Planned Future Updates � Consolidation of Candidate Questionnaires � Addition of newly approved DOAC agents � Advanced Adherence / Compliance Metrics
Planned Future Updates � Consolidation of Candidate Questionnaires � Addition of newly approved DOAC agents � Advanced Adherence / Compliance Metrics
Consolidation of Candidate Questionnaires � One common initiation questionnaire that can be used to enroll patients on all DOAC agents will lead to increased ease of use. � Follow Up questionnaires stratified by DOAC agent will remain at first – However, similarities between Follow Up questionnaires may eventually lead to consolidation as well
Planned Future Updates � Consolidation of Candidate Questionnaires � Addition of newly approved DOAC agents � Advanced Adherence / Compliance Metrics
Addition of Newly Approved DOAC Agents � Betrixaban (Bevyxxa) was approved by FDA in June 2017 for VTE prevention after hospitalization for acute medical illness – 160mg as a single dose on Day 1, followed by 80mg once daily for 35 to 42 days � BWH likely to see use due to involvement with clinical trial (APEX) leading to approval � Candidate / Follow Up Questionnaires will be created that document and assess patient characteristics as done with the other DOAC agents Cohen AT, Harrington RA, Goldhaber SZ, et al. Extended thromboprophylaxis with betrixaban in acutely ill medical patients. N Engl J Med. 2016;375(6):534-544. doi: 10.1056/NEJMoa1601747.
Planned Future Updates � Consolidation of Candidate Questionnaires � Addition of newly approved DOAC agents � Advanced Adherence / Compliance Metrics
Advanced Adherence / Compliance Metrics � Goal is to provide quantitative data that can be used to for future collection and analysis � Modified Morisky Scale (MMS) – 6 question, binary assessment that provides feedback on patient’s knowledge and adherence related motivation � Compliance determined by timing of prescription refills
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