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Direct oral anticoagulant (DOAC) monitoring within primary care: a quality improvement project
Isobel Joy McFadzean1, Rhian Francis2, Catrin Fischetti2
1Swansea Bay University Health Board, Port Talbot, UK mcfadzeanj@cardiff.ac.uk.
Insights
Monitoring direct oral anticoagulants (DOACs) is crucial for patient safety. This quality improvement project successfully enhanced DOAC monitoring compliance in general practice, reducing adverse event risks.
Area of Science:
- Pharmacology
- Patient Safety
- Quality Improvement in Healthcare
Background:
- Poor monitoring of anticoagulants, including direct oral anticoagulants (DOACs), poses significant patient safety risks like hemorrhage or clotting.
- Despite DOACs comprising 62% of anticoagulant prescriptions, healthcare professionals often lack familiarity with their specific monitoring needs compared to warfarin.
- Inadequate monitoring processes in general practice (GP) necessitate targeted quality improvement (QI) initiatives.
Purpose of the Study:
- To enhance the compliance of direct oral anticoagulant (DOAC) monitoring within a general practice setting.
- To implement sustainable processes for DOAC monitoring using quality improvement (QI) methodology.
- To improve patient safety and mitigate the risk of adverse outcomes associated with DOAC therapy.
Main Methods:
- Utilized quality improvement (QI) methodology, including Plan-Do-Study-Act (PDSA) cycles, to develop and implement new monitoring processes.
- Focused on increasing DOAC monitoring compliance by a target of 20% within a 6-month timeframe.
- Engaged stakeholders and integrated anticoagulant domains into a nationwide Quality Assurance and Improvement Framework.
Main Results:
- Within 6 months, DOAC monitoring improved, with 49% of patients attending a DOAC clinic and 78% receiving DOAC counseling.
- Achieved high compliance for essential monitoring parameters: 97% had appropriate blood tests, and 72% had recent weight records.
- Three years post-intervention, 74% of 600 patients on DOACs received annual reviews aligned with project standards.
Conclusions:
- Quality improvement (QI) projects effectively enhance direct oral anticoagulant (DOAC) monitoring in primary care.
- Implementing PDSA cycles, stakeholder engagement, and standardized frameworks improves patient safety in anticoagulant management.
- Sustainable improvements in DOAC monitoring are achievable within general practice, leading to better patient outcomes.
Background:
Poor monitoring of anticoagulants is a significant area of patient safety. It can lead to the dichotomous risk of haemorrhage/clotting without appropriate counselling and monitoring. While healthcare professionals may be familiar with the anticoagulant warfarin and the international normalised ratio, they might be unaware of the monitoring requirements of direct oral anticoagulants (DOACs), despite DOACs making up 62% of anticoagulants prescribed. The goal of this quality improvement (QI) project was to increase the compliance of monitoring of DOACs within general practice (GP) to improve patient safety and reduce the risk of an adverse outcome for patients.
Local Problem:
In 2019, the GP surgery had 318 patients prescribed a DOAC and their medication reviews took place opportunistically. While initially, monitoring levels were nearly 100%, by December 2018 this had dropped significantly, and clinicians stated they were unfamiliar with this medication.
Methods And Interventions:
This project aimed to resolve this by using QI methodology and Plan-Do-Study-Act (PSDA) cycles to create new sustainable processes with DOAC monitoring and aimed to increase DOAC monitoring by 20% within 6 months.
Results:
Within 6 months, the project improved the rate of monitoring, and 49% of all patients prescribed a DOAC were seen in a DOAC clinic (n=156) and 78% (n=230/294) had DOAC counselling; 97% (n=295/304) had appropriate blood tests and 72% (n=216/298) had a recent weight recorded within their medical records. Three years on, 600 patients within the practice are prescribed DOACs and 74% (n=445) have had an annual review adhering to the gold standards set within the project.
Conclusion:
This QI project confirms that monitoring of DOACs can be improved within primary care by using QI methodology and improving patient safety, using PDSA cycles, stakeholder engagement and the introduction of the anticoagulant domains within the nationwide Quality Assurance and Improvement Framework.
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