Implementation of Anticoagulation Patient Self-Testing in an ...

1. 1 Implementation of Anticoagulation Patient Self-Testing in an Indian Health Service Facility LT John Bousum, Pharm.D. Pharmacy Resident Claremore Indian Hospital

2. 2 Objectives List the requirements for patient self-testing (PST) by the Centers for Medicare and Medicaid Services (CMS) Explain the potential role of PST in the management of anticoagulation therapy

3. 3 2008 CHEST Guidelines 4.3.1. �In patients who are suitably selected and trained, PST is an effective alternative treatment model. We suggest that such therapeutic management be implemented where suitable.� (Grade 2B)

4. 4 Warfarin: Black Box Warning Regular monitoring of INR should be performed on all treated patients Those at high risk of bleeding may benefit from more frequent INR monitoring

5. 5 CMS Requirements Chronic oral anticoagulation with warfarin Mechanical heart valve (exluding porcine) Chronic atrial fibrillation Venous thromboembolism (DVT and PE) = 3 months of anticoagulation prior to PST Face-to-face training Correct use of the point-of-care device Test no more than once a week

6. 6 CMS Billing Codes

7. 7 CLIA-Waived POC Devices

8. 8 PST Reimbursement

9. 9 Annual Reimbursement

10. 10 Criteria for Patient Selection Willing to participate Able to use POC device report results attend visits Reliable in following instructions Accessible via telephone

11. 11 Barriers to PST

12. 12 Reasons for PST Improved time in therapeutic range (TTR) Improved patient understanding of warfarin therapy Ease of burden for providers Convenience for patients Improved quality of care

13. 13 Research Support Systematic review and meta-analysis 14 randomized trials of PST Results: reductions in�

14. 14 Implementation of PST Program Objective: feasibility of PST in an IHS facility Methods: Prospective observational analysis Face-to-face training by pharmacist Assessment of TTR 3 months before and after training Determined by linear interpolation Patient satisfaction survey using Likert scale

15. 15 Baseline Demographics

16. 16 Aortic Valve Results

17. 17 Mitral Valve Results

18. 18 Combined Results

19. 19 Problems Forgetting to test Forgetting to report INR Improper technique Time constraints for patient contact

20. 20 Next Step Reevaluate policy and procedures Expand service to include more patients Further defining eligibility criteria Investigate options for billing

21. 21 Patient Self-Testing LT John Bousum, Pharm.D. Pharmacy Resident Claremore Indian Hospital john.bousum@ihs.gov