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Our Mission
The Anticoagulation Forum is a multidisciplinary nonprofit organization of healthcare professionals that will improve the quality of care for patients taking antithrombotic medications.
Board of Directors
David Garcia, MD
Jack Ansell, MD
Mark Crowther, MD
Janet Delaney, MSN, ARNP
Alan Jacobson, MD
Scott Kaatz, DO
Stephan Moll, MD
Edith Nutescu, PharmD
Lynn Oertel, MS
Terri Schnurr, RN
Daniel Witt, PharmD
Ann Wittkowsky, PharmD
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Executive Director
Anticoagulation Forum
This newsletter is provided for informational purposes only and is not intended to provide specific medical advice, diagnosis, or treatment. You should always seek advice from a physician or other qualified health care provider for your individual medical needs. The AC Forum does not endorse or recommend any commercial products. | |
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UPDATE: AFib Grand Rounds Program
The Anticoagulation Forum is pleased to announce the launch of its Preventing Atrial Fibrillation Related Strokes with Anticoagulants Grand Rounds Program. Beginning this fall, the AC Forum will partner with Boston University School of Medicine to bring community based hospitals this exciting opportunity to hear from leaders in the field of anticoagulation therapy.
The goal of this program is to inform health care professionals about current treatment and best practices in the use of anticoagulation therapy for preventing stroke in patients with atrial fibrillation(AFib). It will also address the implementation of the new therapeutic treatment options, current guidelines, and best practices.
Beginning September 2012 through June 2013, these one-hour educational sessions will include nationally renowned speakers who will provide onsite, interactive presentations at 15 community based hospitals nationwide.
Response to the Anticoagulation Forum's request by interested hospitals was overwhelming. Thank you to all AC Forum members that responded with interest in having this program brought to their hospitals. The AC Forum hopes to bring this Grand Rounds program to more hospitals in the future.
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New Program Coming Soon:
Anticoagulation Centers of Excellence
The AC Forum has embarked on an exciting new project called "Anticoagulation Centers of Excellence". Plans are underway to build a comprehensive website and an interactive assessment tool that will help to define the ideal practices a clinic should be using to provide the best possible care. The website will debut in late 2012. Upon successful completion, clinics will be recognized as an Anticoagulation Center of Excellence. This self-assessment program will be built on 5 pillars of care. They are:
- Patient & Family Education
- Disease State Management
- Drug Therapy Management
- Transition of Care & Coordination of Care
- Quality/Clinic Operational Performance
When clinics enroll, they will gain insight on how their clinic performs compared to recommended guidelines and gain access to a website with extensive resources including examples of best practice, allowing them to make improvement toward excellence.
As we begin to shape the criteria for this designation, we are asking members to forward policies and best practices that you believe have elevated patient care at your clinic. We will in turn share some of these examples with other AC Forum members. Please forward material that you are willing to share to Elizabeth Goldstein, Executive Director, Anticoagulation Forum at egoldstein@acforum.org. We look forward to bringing the Anticoagulation Centers of Excellence program to our membership.
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Ask Janet
How does dabigatran affect INR?
This question was recently posted on a relevant list serve and resulted in a number of responses. In reviewing the responses posted it appears that the group has a general understanding that it does but no understanding as to why. This concerned me, as I believe that we all need to possess an understanding of what we are really measuring when we do coagulation assays.
The prothrombin time is used to assess the coagulation activity of the extrinsic and common coagulation pathways. It measures the functional activity of factors I, II, V, VII, X. It is reported in seconds as the time it takes for a plasma sample to clot following addition of thromboplastin. The international normalized ratio (INR) is a way to standardize PT results between laboratories, irrespective of which thromboplastin reagent is being used.
Warfarin inhibits the production of vitamin K dependent clotting factors II, VII, IX, X. It results in the synthesis of dysfunctional clotting factors. The PT/INR is relatively insensitive to minor reductions in clotting factor activity and least sensitive to FII. Warfarin has a prolonged pharmacodynamic effect because some of the vitamin K-dependent clotting factors have long half-lives, thus making the PT/INR abnormal for up to several days after the last dose of warfarin.
Dabigatran is a direct inhibitor of factor IIa. Since dabigatran antagonizes the thrombin-mediated conversion of fibrinogen to fibrin, it can affect all of the routine coagulation assays. The correlation between plasma dabigatran concentration and the degree of PT prolongation is poor. A completely normal prothrombin time likely excludes the presence of any significant dabigatran effect but a prolonged PT (or elevated INR) cannot be interpreted, except to say that some anticoagulant effect is present. Therefore, a patient on dabigatran may have an elevated INR, but the INR does not necessarily reflect the drug's physiologic effect on coagulation. Although a normal PT may occasionally be useful to a clinician trying to decide whether any dabigatran-related anticoagulant effect is present, the INR was designed specifically to assess the effect of warfarin and has no role in the evaluation of a patient with dabigatran. Finally, if dabigatran is being used as a bridge to warfarin, the PT/INR test will be difficult (if not impossible) to interpret because the INR may be elevated partly by dabigatran and partly by warfarin. Using dabigatran as a bridge to warfarin is therefore NOT RECOMMENDED under any circumstances.
Hope this helps!
JD
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Alliance for Aging Research Releases New Atrial Fibrillation Consensus and Survey;
Results Show Less than 50% of Physicians Use Stroke Risk Assessment Tools Regularly. Expert Consensus Statement Recommends Process for Assessing Stroke and Bleeding Risk for Appropriate Anticoagulant Use
WASHINGTON, DC (July 19, 2012) - The Alliance for Aging Research (Alliance) announced the release of a new consensus statement written by leading experts in the area of stroke prevention in atrial fibrillation (AFib). The consensus development was spearheaded by the Atrial Fibrillation Optimal Treatment Task Force, led by the Alliance. The resulting statement provides a standardized approach to assessing moderate- to high-risk patients and determining who should be on an anticoagulant medication. Additionally, the document presents the leading stroke and bleeding risk tools all in one place - making them easy for health care professionals to access and compare.
Despite the high risk of stroke in patients with atrial fibrillation - which is around 2 to 7 times greater than in those without the disease - anticoagulation therapy is still underused. According to a recent survey conducted by Edge Research on behalf of the Alliance and the AFib Optimal Treatment Task Force, 66% of physicians surveyed report that the number of clinical guidelines and tools in this area cause confusion, and 48% report that there are too many ambiguities in those guidelines. Additionally, only half of physicians reported being familiar with those guidelines that provide recommendations for assessing and treating the condition.
The primary objective of the AFib Optimal Treatment Task Force
was to reduce the burden of stroke in AFib by creating consensus on the best practices for assessing stroke and bleeding risk in anticoagulation decision-making. The Task Force convened a roundtable of leading experts in cardiology, neurology, anticoagulants, and more to address this challenge and develop a consensus statement.
The consensus statement provides guidance on: (1) The process for assessing risk and making anticoagulant decisions in AFib; (2) Making decisions on anticoagulants in a landscape with increasing options; and (3) Promising areas of research requiring additional investigation.
In the consensus statement, the experts recommend a three-step approach to anticoagulation decision-making in patients with AFib:
- First, a patient's stroke risk should be assessed and recorded no less than annually using an established scoring tool. Those identified as intermediate or high risk should be put on an anticoagulant - warfarin or a direct thrombin inhibitor or a factor Xa inhibitor. Aspirin is not recommended for stroke prophylaxis in AFib.
- Second, if the patient is at high enough risk to require anticoagulation therapy, the patient's bleeding risk should then be evaluated to estimate the net clinical benefit of an anticoagulant, again using an available tool as a starting point. Risk factors for intracranial hemorrhage should be considered although routine screening for these risk factors is not currently indicated.
- For the majority of patients, the net benefit of stroke prophylaxis supersedes the "net harm" of serious bleeding events - even in older patients. The experts also emphasized that assessment of bleeding risk is not an opportunity to look for reasons not to anticoagulate, but an opportunity to address correctable risk factors for bleeding.
- Third, the decision to undergo anticoagulation therapy must reflect patient preferences and values. The patient must also understand the relative benefits and risks and be involved in the discussion and ultimate decision surrounding the clinical net benefit of anticoagulation therapy.
The consensus experts also recommended that education programs and tools be enhanced and disseminated at the primary care and family practitioner levels. For example, establishing stroke risk assessment tools for use in EMR systems, conducting public awareness activities and events at medical centers, educational initiatives by payers, pocket guides, and on-line resources.
Finally, the consensus experts called for enhanced patient education materials, tools, and outreach. Many patients are not aware that AFib confers a five-fold increase in stroke risk and participants recommended initiatives that prompt conversations about stroke risk between patients and medical providers. The task force also suggested that organizations join forces to promote accurate and objective healthcare information with a consistent message and voice.
Three members of the AC Forum Board of Directors participated as expert panelists. Those members included: Dr.David Garcia, Dr. Alan Jacobson, and Dr. Edith Nutescu
For more information about Atrial Fibrillation, please visit the Alliance for Aging Research Web site at:.http://www.agingresearch.org/section/topic/atrialfibrillation/consensusstatement/
About the Alliance for Aging Research
Founded in 1986, the Alliance for Aging Research (Alliance) is a nonprofit, independent organization dedicated to improving the health and independence of aging Americans through public and private funding of medical research and geriatric education. The Alliance combines the interest of top scientists, public officials, business executives, and foundation leaders to promote a greater national investment in research and new technologies that will prepare our nation for the coming senior boom, and improve the quality of life for today's older generation. For more information, visit: http://www.agingresearch.org.
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Masspro QIO Initiative
Masspro, the federally funded Quality Improvement Organization (QIO) for Massachusetts, is working with clinical pharmacists, primary care clinics, and other providers caring for patients that are at risk for the negative consequences of warfarin therapy, in a patient focused, community based effort aimed at improving medication safety.
Safe and effective use of warfarin remains a challenge due to the complex dose-response relationship that is inherent in its management. Warfarin, while effective, presents a uniqu
e and complex pharmacology that has the potential to significantly contribute to adverse drug events (ADE's) if not managed effectively.
Providers who join this initiative will:
- Contribute to the national goal of reducing ADE's in 265,000 lives per year
- Improve healthcare in Massachusetts though the integration of clinical pharmacy services into the care and management of these high risk, high cost and complex patients.
- Take a primary role in improving the health for patients, showcase best practices, and be a leader in medication safety.
Masspro brings the expertise of quality improvement professionals, with a unique understanding of system changes, that have the potential to reduce the burden associated with medication-related adverse events.
Anticoagulation clinics bring the expertise of a team experienced in pharmacist managed anticoagulation therapy proven to be safer than traditional care.
Togetherwe can significantly impact the lives of our patients.
If you are providing medication management services in Massachusetts, are committed to partnering in the efforts of the national agenda to reduce adverse drug events, or are interested in learning more, please contact Salpi Stepanian, PharmD at sstepanian@maqio.sdps.org or call 781-419-2887.
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IPRO/New York Anticoagulation Coalition Disseminates Analytic Resources
IPRO, the CMS-designated Quality Improvement Organization (QIO) for New York State, is presently leading a state-wide warfarin safety campaign seeking to improve time in therapeutic range (TTR) and reduce adverse drug events involving anticoagulants. To support this effort, IPRO has constituted the New York Anticoagulation Coalition and is directly collaborating with large provider groups and health systems from Buffalo to Long Island.
High quality data collection, analysis and reporting is vital to the effective management of warfarin users, and IPRO has recently posted data tables and analytic code to their web page to support groups seeking to improve the quality of anticoagulation-related services (http://www.ipro.org/index/ds-ac). While the Coalition itself is intended to specifically improve the quality of patient care in New York, the analytic resources are available free of charge to others through the Coalition web page. For more information on CMS-funded Quality Improvement Organizations or to locate the QIO in your state visit: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.3-12-24
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