Pharmacists at the Forefront: Leveraging Data and Stewardship Models to Transform Anticoagulation Management

As direct oral anticoagulants (DOACs) have replaced warfarin for many patients, a critical gap has emerged: unlike warfarin, DOACs don't require regular lab visits, leaving health systems without the built-in touch points needed to catch dosing errors, adherence problems, or inappropriate use.

In this conversation, Darren Triller, PharmD, senior director of strategic initiatives at the Anticoagulation Forum, makes the case for system-level solutions over individual clinical effort, introducing the ADAPT framework—5 high-priority areas where pharmacists can drive measurable improvements in patient outcomes. Drawing on pioneering work from the VA and Michigan's MACQI program, the discussion highlights how population health dashboards are enabling pharmacists to efficiently manage tens of thousands of anticoagulated patients, flag those most at risk, and deliver interventions that are now backed by hard clinical outcome data.

Q: Your presentation tomorrow emphasizes modifiable risk factors linked to avoidable harms in patients on oral anticoagulants. Which of these factors are pharmacists best positioned to really make a difference on, and why?

Darren Triller, PharmD: That's a great question. Before I answer, I just want to make sure that the audience understands that we're discussing things in the context of an antithrombotic or anticoagulation stewardship model—so we're thinking at the system level. While it's wonderful to have individual clinicians paying attention and doing great things, what we're really advocating for is system-level changes. The other thing to provide context is our ADAPT project. ADAPT is an acronym for 5 high-priority areas in ambulatory care anticoagulation management: appropriate antithrombotic use, direct oral anticoagulant (DOAC) dosing, DOAC adherence, periprocedural management of anticoagulants, and time in therapeutic range for warfarin.

Of those 5, the most tailor-made, plug-and-play area is really adherence, because pharmacists have data whether you're at a managed care plan, whether you're at a community pharmacy, or whether you're in a health system. The data already exist. The infrastructure already exists. The measures already exist. The Pharmacy Quality Alliance (PQA) already has a National Quality Forum (NQF)-endorsed quality measure for DOAC adherence. So I think that's the most plug-and-play-ready area, and it really falls into the pharmacist realm for managing. The other areas are all super important — and we can get into those with the other questions — but they require different levels of data and are more complex. Adherence is bread-and-butter pharmacy, and we really think that part of stewardship is people owning things at the system level. Of those 5, adherence is something pharmacy could step up to, should step up, and own, regardless of what setting they're in.

Q: The ADAPT study highlighted gaps in appropriate DOAC dosing, with nearly 1 in 4 patients receiving an incorrect dose. What are the system-level or workflow strategies that you recommend to help improve that optimization across large populations?

Triller: This is really important and really interesting. You introduced the term "population," so we're really talking about population health. Again, in the spirit of context, with warfarin, everyone was familiar with it; patients had to come in regularly for blood work, and there were all those set touch points. With DOACs, that's not the case. So we're in a situation where someone needs to decide how often, with which patients, and when we need to have those touch points.

There are 2 health systems nationally that have really been out in front on this. One is the Veterans Administration (VA), which had and still has a large number of warfarin management clinics and converted or added management of DOACs. The other is the MiCQI program—the Michigan Anticoagulation Quality Improvement Initiative—which is a statewide collaborative.

What both programs realized is that it does not make sense to try to see every patient on a DOAC regularly—once a month, once every 3 months, and so on—because, as you already touched on, the majority of patients are on the correct dose. So what they've endeavored to do is create population health management dashboards using available data sources. What that allows them to do is take 10,000 or 100,000 patients under their purview who are on DOACs and have the dashboard flag those patients with potential problems. By doing so, they've focused the limited, scarce resources of pharmacists on the patients most likely to need intervention.

They started in 1 Veterans Integrated Service Network (VISN)—1 of the regions in the VA—and have now scaled nationally for DOAC management over a number of years. They have shown that they increase the number of interventions pharmacists are making on DOAC patients and that pharmacists can intervene faster because the dashboard provides the data. They now have data showing hard outcomes in the context of thrombotic events and bleeding. The VA now has many years of data and multiple publications—I sent you a link to 1 or 2 of those that you can share—and population health management via a digital dashboard is really the standard of care. The dashboard distills and flags patients for potential dosing issues based on adherence or indication, and it incorporates lab data and patient weights to ensure correct dosing. Using this approach, they can manage tens and tens of thousands of patients and improve their outcomes.

The MiCQI program has replicated that as well in their clinics across the state of Michigan, with very similar results. I believe they started out mostly with proper dosing and adherence and have now layered in appropriate antithrombotic or antiplatelet use—so 3 of the 5 ADAPT concepts are embedded into those programs. Both are homegrown systems: the VA built their own, and I believe the Michigan team built theirs in Epic. There is now at least 1 proprietary vendor—which we're not going to mention by name here—that offers a commercial platform to support a dashboard for a health system, a managed care plan, clinics, and similar settings.

So: dashboard. If I didn't say it enough, dashboard.