Infectious Disease

COVID-19 forces modifications to INR assessments for sufferers taking vitamin Okay antagonists

February 17, 2021

2 min read

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Musialowski does not report any relevant financial information.

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The onset of the COVID-19 pandemic forced health systems to adapt clinical practice to limit patient exposure and centralize telehealth into routine care while continuing to ensure adequate care.

At the Atrium Health Sanger Cardiovascular Institute in Charlotte, North Carolina, physicians have undertaken a major transformation to meet the needs of thousands of high-risk patients receiving vitamin K antagonist therapy, where patients frequently go to health facilities for INR- Tests need to appear. Vitamin K antagonist therapy, most commonly warfarin in the US, is prescribed for stroke prevention in patients with atrial fibrillation and for prevention of venous thromboembolism in high-risk patients.

Rick Musialowski, MD, Director of Cardiovascular Education at the Sanger Heart and Vascular Institute.

In a comment published in NEJM Catalyst, Sanger doctors outlined these changes, including actively switching patients to a direct oral anticoagulant that does not require INR testing based on appropriate indications. Extension of the INR test intervals; and establishing mobile INR tests that reduce face-to-face contact for patients in need of ongoing management.

Healio spoke to Rick Musialowski, MD, Director of Cardiovascular Education at the Sanger Heart and Vascular Institute, on the challenges of the transition and future of telemedicine.

Healio: What key changes have Sanger made to minimize the risk for patients receiving vitamin K antagonist therapy?

Musialowski: Our team made extensive and rapid changes in 2,312 patients with vitamin K antagonists. Within 5 weeks, we switched 437 patients to an alternative drug that no longer required a personal point-of-care test or limited exposure to COVID-19. At the same time, the interval between the point-of-care tests for the remaining patients was reassessed and safely extended. Eventually, 975 of the remaining patients in need of on-site INR monitoring were offered home monitoring. We reduced personal point of care testing by 63% over a period of one year. Drive-up and outdoor point-of-care tests were also conducted during the height of the pandemic.

Healio: Were there any hurdles to overcome during this transition?

Musialowski: Home INR tests are carried out by an independent provider and require insurance pre-certification. There was a registration and application process that delayed implementation. To streamline this process, we worked with a single provider and the formal prescription was submitted by a single provider. Not all insurance companies offer adequate coverage. The cost is prohibitive for a large proportion of the 367 patients who have yet to come to the office for point-of-care tests.

Healio: Were there any noticeable changes in drug adherence during this transition?

Musialowski: In the first 8 months there was a significant 26% number who couldn’t afford the newer and safer medicine. These patients had to resume vitamin K antagonists and INR tests were offered at home. Compliance with the vitamin K antagonists remained unchanged compared to the basic care.

Healio: Do you plan to return personal visits?

Musialowski: Telemedicine is becoming a major part of health care. There will always be a role for personal visits. Certain disease states and important discussions are always better in person. The doctor-patient relationship is currently evolving.

Healio: What’s the takeaway message for doctors seeing high-risk patients like those in this cohort?

Musialowski: We encourage healthcare systems to first evaluate the clinical infrastructure and workflows associated with current patient care. Problems such as cost (including costs incurred directly by the patient), convenience, preference, and access limit what can be achieved with a large amount of change. A rapid transformation of service delivery while ensuring patient safety is possible, but requires detailed planning and support for all aspects of service delivery.

Healio: Would you like to add anything else?

Musialowski: A partnership has been established with the pharmaceutical industry to facilitate conversion using free samples during the height of the pandemic. The results of the study are currently being evaluated. This includes major CV adverse events, medication compliance, bleeding complications, and COVID-19 status. The results should be completed in the next few months.

For more informations:

Rick Musialowski, MD, accessible at the Sanger Heart and Vascular Institute – Pineville, 10650 Park Road, Suite 220, Charlotte, NC 28210.

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