title: Reimagining Anticoagulation Clinics in the Era of Direct Oral Anticoagulants.
abstract: Anticoagulation clinics were initially developed to provide safe and effective care for warfarin-treated patients with atrial fibrillation, venous thromboembolism, and mechanical valve replacement. Traditionally, these patients required ongoing laboratory monitoring and warfarin dose adjustment by expert providers. With the introduction of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban), many have questioned the need for anticoagulation clinic. However, we think that the growing number of oral anticoagulant choices creates an urgent need for expanding the traditional role of the anticoagulation clinic. We outline 3 key purposes that a reimagined anticoagulation clinic would serve: (1) to assist patients and clinicians with selecting the most appropriate drug and dose from a growing list of anticoagulant options (including warfarin), (2) to help patients minimize the risk of serious bleeding complications with careful long-term monitoring and peri-procedural management, and (3) to encourage ongoing adherence to these life-saving medications. We also describe how repurposing anticoagulation clinics as broader medication safety clinics would promote safe and effective care across a range of cardiovascular conditions for high-risk medications (eg, spironolactone, amiodarone). Finally, we highlight a few existing health systems that are overcoming key challenges to implementing a reimagined anticoagulation or medication safety clinic structure.
authors.affiliation: From the Frankel Cardiovascular Center, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor (G.D.B., B.K.N., J.B.F.); and Department of Learning Health Science, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare Center, Ann Arbor, MI (A.E.S.). gbarnes@umich.edu.
authors.forename: Geoffrey D
authors.initials: GD
authors.lastname: Barnes
authors.affiliation: From the Frankel Cardiovascular Center, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor (G.D.B., B.K.N., J.B.F.); and Department of Learning Health Science, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare Center, Ann Arbor, MI (A.E.S.).
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.affiliation: From the Frankel Cardiovascular Center, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor (G.D.B., B.K.N., J.B.F.); and Department of Learning Health Science, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare Center, Ann Arbor, MI (A.E.S.).
authors.forename: Anne E
authors.initials: AE
authors.lastname: Sales
authors.affiliation: From the Frankel Cardiovascular Center, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor (G.D.B., B.K.N., J.B.F.); and Department of Learning Health Science, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare Center, Ann Arbor, MI (A.E.S.).
authors.forename: James B
authors.initials: JB
authors.lastname: Froehlich
mesh_terms: D000284:Administration, Oral; D000554:Ambulatory Care Facilities / Q000458:organization & administration; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001777:Blood Coagulation / Q000187:drug effects*; D001780:Blood Coagulation Tests; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration; D054796:Drug Dosage Calculations; D016903:Drug Monitoring / Q000379:methods; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D018579:Patient Selection; D011237:Predictive Value of Tests; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: anticoagulant; anticoagulation; nurse management; pharmacist management; warfarin