What an exciting time to reflect on advances in anticoagulation management, and spotlight point of care clinicians dedicated to translating excellence into action. The stage was Austin, Texas, and featured a compact, 2-day Anticoagulation (AC) Boot Camp hosted by the AC Forum board of Directors on April 23rd and 24th. A nationally recognized panel of AC experts presented on critical touch points in AC management and emerging research trends. The panel also engaged attendees in open and rigorous discussion during “chalk talk” sessions. Attendees and experts alike wrestled with the challenges of AC management to include transition in care, health information exchange, new AC agents, quality improvement, and special populations.
The intimate setting, diverse clinical representation and camaraderie of the expert panel was unlike most conferences I have attended. There was a very open and transparent mood but a sense of urgency and weightiness to the meeting cadence. I heard it said in many ways, “we are in this together and we don’t have all the answers but if we put our heads together and wrestle with reality then great things can happen.” There was nothing pretentious about it. The general sense was that we have come so far but there is still so much at stake.
Dr. Renato Lopez, Co-Director of the Integrated Clinical Event Safety Surveillance at Duke Clinical Research Institute, presented on common indications for prosthetic heart valves. Dr. Lopez challenges the group by pointing to a lack of high quality data to inform many of our decisions. He soberly reminds the attendees that currently only 0.3% of evidence-based guidelines for valvular disease are supported with level A (high) evidence. He also points out that for many common cardiovascular conditions it is not much better. For atrial fibrillation it is 11.7% and in well-known disease states such as STEMIs* it’s only 13.5%. According to Tricoci, et al. (2009),
“…the current system generating research is inadequate to satisfy the information needs of caregivers and patients in determining benefits and risks of drugs, devices, and procedures.”
The imperative is to acknowledge scientific limitations to patients, engage in shared decision-making and support efforts to capture, track, report and communicate information in a meaningful way.
Day two focused on Transition of Care (ToC) cases. Several experts presented on Innovative ToC programs to include Project RED presented by Dr. Brian Jack from Boston University. Dr. Jack reports that post-discharge adverse events are problematic and lead to preventable ER visits and re-admissions (Jack, 2009). There was an urgency to increase efforts to reduce AC associated ADEs* and the need to adopt innovative tools to tackle this problem.
Pharmacist, Dr. Allison Burnett, presented on leveraging the Electronic Health Record (EHR) in innovative ways to capture Requisite Data Elements (RDEs) that should be communicated to “downstream” providers in a concise discharge summary for all anticoagulated patients undergoing care transitions. Dr. Burnett points out that up to 50% of discharged patients experience a medical error within 4-6 weeks, most are medication-related, and associated with high readmission rates (Gandara, 2008; Gandara, 2009). Currently, if the “downstream” provider, such as a primary care doctor or long-term health care facility gets a discharge report, it often consists of 20 or more pages that the provider has to try and make sense of. Information is lost and mistakes to include omission of treatment may result in devastating thromboembolic events (Xian, 2017). As Jay Syverson, President of Point of Care Decision Support, has stated, “We need to do better.”
A big take away from these sessions was the importance of transparency, meaningful information exchange, and partnerships that promote collective problem solving and innovation. I walked away feeling a sense of connection and direction. Point of care clinicians are a vital source of learning and innovation, and I believe if we put our heads together and wrestle with reality then great things can happen.
Share with us your experience during transitions of care and your ideas to shape decision support tools.
*STEMI: ST-Elevation Myocardial Infarction
*ADE: Adverse Drug Events
Gandara E , Moniz T , Ungar J, et al. Communication and information deficits in patients discharged to rehabilitation facilities: An evaluation of five acute care hospitals. J. Hosp. Med. 2009;4:E28-E33. doi:10.1002/jhm.474
Gandara E, Moniz TT, Ungar J, et al. Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation. Jt Comm J Qual Patient Saf. 2008;34(8):460-463.
Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Ann Intern Med. 2009;150:178–187. doi: 10.7326/0003-4819-150-3-200902030-00007
Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC. Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines. JAMA. 2009;301(8):831–841. doi:10.1001/jama.2009.205
Xian Y, O’Brien EC, Liang, et al. Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patient s with atrial fibrillation. JAMA. 2017;317(10):1057-1067.