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CC BY 4.0 · TH Open 2023; 07(03): e184-e190
DOI: 10.1055/a-2098-6782
Original Article

Potential for a Virtual Care Model in the Perioperative Management of Anticoagulant Therapy: A 5-Year Retrospective Clinic Review

James Luke Douketis
1   Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
,
Sam Schulman 
1   Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
2   Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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Abstract

Background With a trend toward greater virtual care in selected clinical settings, perioperative anticoagulant management appears well suited for this care delivery model. We explored the potential for virtual care among patients who are receiving anticoagulant therapy and require perioperative management around the time of an elective surgery/procedure.

Methods We undertook a retrospective review of patients who were receiving anticoagulant therapy, either a direct oral anticoagulant (DOAC) or warfarin, assessed in a perioperative anticoagulation-bridging clinic over a 5-year period from 2016 to 2020. Using prespecified criteria, we determined the proportion of patients who likely would be suitable for virtual care (receiving a DOAC or warfarin and having a minimal- or low-/moderate-bleed-risk surgery/procedure), those who likely would be suitable for in-person care (receiving warfarin and requiring heparin bridging for a mechanical heart valve), and patients who would be suitable for either care delivery model (receiving a DOAC or warfarin, but not with a mechanical heart valve, and requiring a high-bleed-risk surgery/procedure).

Results During the 5-year study period, there were 4,609 patients assessed for perioperative anticoagulant management in whom the most widely used anticoagulants were warfarin (37%), apixaban (30%), and rivaroxaban (24%). Within each year assessed, 4 to 20% of all patients were undergoing a minimal-bleed-risk procedure, 76 to 82% were undergoing a low-/moderate-bleed-risk surgery/procedure, and 10 to 39% were undergoing a high-bleed-risk surgery/procedure. The proportion of patients considered suitable for virtual, in-person, or either virtual or in-person management was 79.6, 7.1, and 13.3%, respectively.

Conclusion In patients who were assessed in a perioperative anticoagulation clinic, there was a high proportion of patients in whom a virtual care model might be suitable.

Keywords

virtual care - perioperative - anticoagulant - heparin bridging - warfarin - direct oral anticoagulants


Publication History

Received: 27 December 2022

Accepted: 17 May 2023

Accepted Manuscript online:
24 May 2023

Article published online:
05 July 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med 2022; 17 (01) 25-35
    CrossrefPubMedGoogle Scholar
  • 2 Shaw JR, Kaplovitch E, Douketis J. Periprocedural management of oral anticoagulation. Med Clin North Am 2020; 104 (04) 709-726
    CrossrefPubMedGoogle Scholar
  • 3 Barnes GD, Ageno W, Castellucci LA. et al. Recommendation on the nomenclature for anticoagulants: updated communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Commitee on the Control of Anticoagulation. J Thromb Haemost 2023; 21 (05) 1381-1384
    CrossrefPubMedGoogle Scholar
  • 4 Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch Intern Med 2004; 164 (12) 1319-1326
    CrossrefPubMedGoogle Scholar
  • 5 Douketis JD, Spyropoulos AC, Kaatz S. et al; BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 2015; 373 (09) 823-833
    CrossrefPubMedGoogle Scholar
  • 6 Spyropoulos AC, Turpie AG, Dunn AS. et al; REGIMEN Investigators. Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on long-term oral anticoagulants: the REGIMEN registry. J Thromb Haemost 2006; 4 (06) 1246-1252
    CrossrefPubMedGoogle Scholar
  • 7 Douketis JD, Spyropoulos AC, Duncan J. et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med 2019; 179 (11) 1469-1478
    CrossrefPubMedGoogle Scholar
  • 8 Kovacs MJ, Wells PS, Anderson DR. et al; PERIOP2 Investigators. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial. BMJ 2021; 373 (1205): n1205
    CrossrefPubMedGoogle Scholar
  • 9 Siegal D, Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 2012; 126 (13) 1630-1639
    CrossrefPubMedGoogle Scholar
  • 10 Spencer NH, Sardo LA, Cordell JP, Douketis JD. Structure and function of a perioperative anticoagulation management clinic. Thromb Res 2019; 182: 167-174
    CrossrefPubMedGoogle Scholar
  • 11 Lesher AP, Shah SR. Telemedicine in the perioperative experience. Semin Pediatr Surg 2018; 27 (02) 102-106
    CrossrefPubMedGoogle Scholar
  • 12 Mihalj M, Carrel T, Gregoric ID. et al. Telemedicine for preoperative assessment during a COVID-19 pandemic: recommendations for clinical care. Best Pract Res Clin Anaesthesiol 2020; 34 (02) 345-351
    CrossrefPubMedGoogle Scholar
  • 13 Miner H, Fatehi A, Ring D, Reichenberg JS. Clinician telemedicine perceptions during the COVID-19 pandemic. Telemed J E Health 2021; 27 (05) 508-512
    CrossrefPubMedGoogle Scholar
  • 14 Barnes GD, Li Y, Gu X. et al. Periprocedural bridging anticoagulation: measuring the impact of a clinical trial on care delivery. Am J Med 2019; 132 (01) 109.e1-109.e7
    CrossrefPubMedGoogle Scholar
  • 15 Talari G, Demertzis ZD, Summey RD, Gill B, Kaatz S. Perioperative management of anticoagulation. Hosp Pract 2020; 48 (05) 231-240
    CrossrefPubMedGoogle Scholar
  • 16 Acosta J, Graves C, Spranger E, Kurlander J, Sales AE, Barnes GD. Periprocedural antithrombotic management from a patient perspective: a qualitative analysis. Am J Med 2019; 132 (04) 525-529
    CrossrefPubMedGoogle Scholar
  • 17 Brundisini F, Giacomini M, DeJean D, Vanstone M, Winsor S, Smith A. Chronic disease patients' experiences with accessing health care in rural and remote areas: a systematic review and qualitative meta-synthesis. Ont Health Technol Assess Ser 2013; 13 (15) 1-33
    PubMedGoogle Scholar
  • 18 Asiri A, AlBishi S, AlMadani W, ElMetwally A, Househ M. The use of telemedicine in surgical care: a systematic review. Acta Inform Med 2018; 26 (03) 201-206
    CrossrefPubMedGoogle Scholar
  • 19 Lum DJ, Ross PA, Bishop MA, Caetano ML, Malpani R, Streiff MB. Evaluation of a standardized perioperative management protocol in the adult hematology anticoagulation management service. Ann Pharmacother 2017; 51 (12) 1077-1083
    CrossrefPubMedGoogle Scholar
  • 20 Moesker MJ, de Groot JF, Damen NL, Huisman MV, de Bruijne MC, Wagner C. How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review. BMJ Open 2019; 9 (07) e029879
    CrossrefPubMedGoogle Scholar
  • 21 Douketis JD, Spyropoulos AC, Murad MH. et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162 (05) e207-e243
    CrossrefPubMedGoogle Scholar