Incorporation of DAWN AC DOAC Modules Into Practice Peter Collins, - - PowerPoint PPT Presentation

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

Induction Dose To Maintenance Dose Transition

Follow Up Questionnaires

Adherence / Compliance

Adverse Events

Follow Up Questionnaires

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

• f 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

• 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

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
• n 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
• f prescription refills

Conclusions

• DAWN AC DOAC modules provide a comprehensive system that allows for

standardized follow up and documentation relating to DOAC therapy

• Although system menus allow for some degree of customization, there is limited

flexibility for managing patients with non-supported indications and extreme renal dysfunction

• Changes to DOAC clinic workflow will be impacted by future changes in patient

population size, patient characteristics, expanding DOAC indications, and more

• Robust reporting features of DAWN AC will continue to be useful going forward to

quantitatively evaluate the value of AMS and quality of provided care

– Combining data from multiple AMS groups may allow for even larger data analysis

Questions?