Does telehealth improve anticoagulation management in patient service centers (PSC)? A pilot project.

Anticoagulation Management Services (AMS) are known to improve warfarin management in the outpatient setting. The guideline recommendations are well established and indicate that patients who receive a Vitamin K antagonist (VKA) should be under the care of an experienced and specialized anticoagulation clinic (Lip et al. in Chest 154(5):1121-1201, 2018). Warfarin, a VKA, is considered a high risk medication and one of the most common causes of adverse events with poor patient outcomes. Anticoagulation care is assessed by measuring the percent of Time in Therapeutic Range (TTR) in patients receiving a VKA. Evidence shows that a 10% improvement in TTR has been associated with a 10% reduction in adverse event rates. Optimal management over usual medical care should prevent 7 myocardial infarctions, strokes, major bleeds, or deaths per 100 patients/year (Bussey et al. in Pharmacotherapy 9(4):214-219, 1989). Telehealth or telemedicine can be defined as the use of electronic information along with telecommunication technologies to provide medical services to individuals that are in remote locations from each other (Perednia in JAMA 273(6):483-488, 1995; Gray et al in J Thromb Thrombolysis 2019(48):690-693, 2019). This technology allows a provider located at a distant site to use two-way audio visual electronic communication to deliver clinical health care services to a patient who is located at an originating site (Kristian et al. Int J Technol Assess Health Care 28(1):44-51, 2012; Testa and Zimmermann in Telemedicine for managing patients on oral anticoagulant, 2011; Telehealth Services in CMS Manual System Pub 100-04 medicare claims processing, 2019). The goals of the Telehealth Anticoagulation Management Service are to: (1) increase patient satisfaction (2) reduce turnaround time for results by providing the INR (International Normal Ratio) results in real time (3) increase patient compliance to INR testing and (4) improve system wide anticoagulation care by increasing cTTR (center Time in Therapeutic Range) metrics to high quality metrics of 65% and above. The overarching goal of our health system Telehealth program was to develop a collaborative care telemedicine INR model in collaboration with core laboratories (Patient Service Centers or PSCs) in order to improve patient quality metrics on warfarin. In this model, the Tele-ACTS Center (Telehealth Anticoagulation and Clinical Thrombosis Service) team was able to provide distant care for the outpatient population on warfarin maintenance therapy using a virtual telemedicine INR model located in a distant location to the PSC. Using this model, we were able to improve center-based TTR by 45.73%.