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

• I have accepted lunches and dinners from all

the DOAC drug companies

Disclosures

• Desert Oasis Healthcare (DOHC)
• perates as an integrated Managed

Healthcare Organization.

• Largest independent practice

associate and includes one of the first full service medical facilities in the Coachella Valley and the High Desert.

• Pharmacists in Population Health and

Prescription Management (PHARxM)

• perate ambulatory care clinics

under established collaborative practice agreements with physicians.

• 30,000 seniors
• 30,000 commercial
• 7,000 ACO patients

Pharmacist Managed Clinic Enrollment Diabetes 825 CAD 296 HepC 59 Anticoagulation 3,300 COPD 519 Refill Program 16,730

• 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

Population Health and Prescription Management (PHARxM)

• 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!

Our Anticoagulation Clinic

• 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

Clinic Workflow

• 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

Phone Follow Up Call

• Losing warfarin patients at a rate greater than

getting replaced by referrals

• Not enough DOAC referrals

Problem 1: Low Patient Volume

Warfarin DOAC

• 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.

Solution 1: Low Patient Volume

“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

Problem 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.

Solution 2: Demonstrating Value

“CAASE” for DOACs

Self reported by patient Pharmacy utilization database

Bleeding/bruising TIA/Stroke/DVT/PE/MI Proper indication Dose adjustment based on labs, concomitant medications, etc. Cost, is it affordable? Lowest Tier? Prior authorization

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!

Solution 2: Demonstrating Value

“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.

Problem 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.)

Solution 3: Interfacing Labs

“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

Problem 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

Solution 4: Cost Issues

• Afib patient on Eliquis for a new DVT. 90 years
• ld, 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?

Problem 5: Difficult Cases

• Your license, your liability
• Doing nothing can be seen as negligence
• Patient safety at stake
• Who do you call?

Solution 5: Difficult Cases

Call Cardiology (or PCP)

• 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

Solution 5: Difficult Cases

• 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

Future Endeavors

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