Leaders: Preventing Hemorrhage Through Research, Team Care

Dr. Margaret Fang, the medical director of the Anticoagulation Clinic at the University of California, San Francisco, has spent the past several years studying ways to prevent hemorrhage in older Americans through proper anticoagulation therapy. As a member of the Kaiser Permanente of North California ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study Group, she is investigating thromboembolic and hemorrhagic outcomes among more than 13,000 atrial fibrillation patients. Most recently, she and her research collaborators developed and evaluated a new risk stratification scoring system to assess the likelihood of anticoagulant-related bleeding in atrial fibrillation patients. (J. Am. Coll. Cardiol. 2011; 58: 395-401).

In an interview with Hospitalist News, Dr. Fang explained some of the recent findings from the ATRIA Study Group and offered her views on the best role for hospitalists in assuring proper anticoagulation therapy.

Hospitalist News: In a recent study, your team evaluated a tool to assess the risk of bleeding in atrial fibrillation patients. How would that tool be used clinically?

DR. FANG: We developed a bleeding risk score called the ATRIA bleed score. It’s specifically designed to be used in patients who are taking anticoagulants. Our goal was to try to use clinical factors to help clinicians and patients estimate the risk of having a major bleeding event while taking an anticoagulant.

There are stroke risk–stratification schemes out there that I think are more widely used in patients who have atrial fibrillation. These are based on their clinical factors and can estimate their annual risk of stroke. Anticoagulants have complications of bleeding too, so it’s important to describe what we think a patient’s risk of bleeding is while on therapy. This score used five fairly easily available clinical factors. Based on whether patients have these risk factors or not, we can counsel them about what their likelihood of having a bleed is in a given year. The range can be as low as less than 1% to nearly 18% per year. Depending on where a patient falls in that risk spectrum and their estimated risk of stroke, you can then decide whether or not it’s worth proceeding with taking anticoagulants.

HN: Do clinicians tend to overestimate bleeding risk?

DR. FANG: I think so. If you look at practice patterns of whether patients with atrial fibrillation are prescribed anticoagulants or not, it shows that almost half of eligible patients are not taking anticoagulants. When you survey physicians as to whether that’s because of a knowledge deficit or something else that’s keeping them from prescribing anticoagulants, the dominant reason is that they think the patient has too high of a bleeding risk or it’s too hard to control or manage the anticoagulants for a given patient. Even though a lot of studies have shown that the consequences of having a stroke are much more severe than the consequences of having a bleed on therapy, a significant proportion of patients with atrial fibrillation are not prescribed anticoagulants.

HN: If the ATRIA bleed score were widely used, would there be more patients who could take advantage of anticoagulation therapy?

DR. FANG: By using this tool, clinicians can find not only the very high-risk patients, but also may be reassured that on average their patients have a lower risk of bleed than what they may have anticipated. They may find that the bleeding risk is not as high as they thought, especially when used in conjunction with a stroke risk scheme.

The other thing to consider is that prescribing anticoagulants will always be a decision that is made with a great deal of patient involvement. So, tools like a stroke risk calculator or a bleeding risk calculator facilitate that discussion and help the patient understand the risks and benefits of therapy.

HN: What does the Anticoagulation Clinic at UCSF do, and how is this different from how anticoagulation is managed at other hospitals?

DR. FANG: Our anticoagulation clinic manages about 600 patients taking chronic anticoagulants. It’s staffed by nurse practitioners and pharmacists who are all trained in anticoagulant management and in our anticoagulation protocols. As the medical director, I’m the only physician who is part of this clinic, and I serve in more of a supervisory role in which I can provide clinical input where needed and help develop standardized protocols and practice patterns. Many of the anticoagulation clinics are built in similar ways.

In the past, much of the anticoagulation management was handled by individual practitioners, such as primary care physicians. But there was an increasing body of literature to support the use of anticoagulation clinics, so now many larger institutions have an anticoagulation management service and an anticoagulation clinic. Some may have physicians working there, but I think that the majority have an interdisciplinary team with pharmacists and nurse practitioners managing most of the patients.

HN: What’s the role of the hospitalist in anticoagulation management?

DR. FANG: Hospitalists pay quite a lot of attention to transitions of care. Attending on the medical service, I understand a little bit about both what people know and what they don’t know about the referral and transitions processes when moving someone to an outpatient anticoagulation clinic. I serve as a liaison and try to think of ways to smooth that transition.

HN: What are the future research areas that are ripe to explore in the anticoagulation field?

DR. FANG: One of the most exciting areas is the development of newer anticoagulants that do not require the frequent blood tests and monitoring that warfarin does. Right now, our anticoagulation clinic exists because warfarin is very challenging to manage and requires very frequent visits. There are newer anticoagulants such as dabigatran and rivaroxaban and several others that are in the pipeline that may obviate the need for warfarin and therefore for anticoagulation clinics.

We know these newer agents seem as good as, if not better than, warfarin in very controlled settings and clinical trials, but we don’t know how they work in the potentially sicker, more difficult to manage populations that we see in the real world. There are certain indications and certain comorbidities that should make clinicians really cautious about using these agents. For instance, we don’t know these agents would perform in older individuals or in those who have renal disease. It’s important to figure out how clinicians are prescribing and using these medications, who they are using them in, and whether the outcomes in the real world are as good as those we’ve seen in clinical trials.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Margaret Fang, the medical director of the Anticoagulation Clinic at the University of California, San Francisco, has spent the past several years studying ways to prevent hemorrhage in older Americans through proper anticoagulation therapy. As a member of the Kaiser Permanente of North California ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study Group, she is investigating thromboembolic and hemorrhagic outcomes among more than 13,000 atrial fibrillation patients. Most recently, she and her research collaborators developed and evaluated a new risk stratification scoring system to assess the likelihood of anticoagulant-related bleeding in atrial fibrillation patients. (J. Am. Coll. Cardiol. 2011; 58: 395-401).

In an interview with Hospitalist News, Dr. Fang explained some of the recent findings from the ATRIA Study Group and offered her views on the best role for hospitalists in assuring proper anticoagulation therapy.

Hospitalist News: In a recent study, your team evaluated a tool to assess the risk of bleeding in atrial fibrillation patients. How would that tool be used clinically?

DR. FANG: We developed a bleeding risk score called the ATRIA bleed score. It’s specifically designed to be used in patients who are taking anticoagulants. Our goal was to try to use clinical factors to help clinicians and patients estimate the risk of having a major bleeding event while taking an anticoagulant.

There are stroke risk–stratification schemes out there that I think are more widely used in patients who have atrial fibrillation. These are based on their clinical factors and can estimate their annual risk of stroke. Anticoagulants have complications of bleeding too, so it’s important to describe what we think a patient’s risk of bleeding is while on therapy. This score used five fairly easily available clinical factors. Based on whether patients have these risk factors or not, we can counsel them about what their likelihood of having a bleed is in a given year. The range can be as low as less than 1% to nearly 18% per year. Depending on where a patient falls in that risk spectrum and their estimated risk of stroke, you can then decide whether or not it’s worth proceeding with taking anticoagulants.

HN: Do clinicians tend to overestimate bleeding risk?

DR. FANG: I think so. If you look at practice patterns of whether patients with atrial fibrillation are prescribed anticoagulants or not, it shows that almost half of eligible patients are not taking anticoagulants. When you survey physicians as to whether that’s because of a knowledge deficit or something else that’s keeping them from prescribing anticoagulants, the dominant reason is that they think the patient has too high of a bleeding risk or it’s too hard to control or manage the anticoagulants for a given patient. Even though a lot of studies have shown that the consequences of having a stroke are much more severe than the consequences of having a bleed on therapy, a significant proportion of patients with atrial fibrillation are not prescribed anticoagulants.

HN: If the ATRIA bleed score were widely used, would there be more patients who could take advantage of anticoagulation therapy?

DR. FANG: By using this tool, clinicians can find not only the very high-risk patients, but also may be reassured that on average their patients have a lower risk of bleed than what they may have anticipated. They may find that the bleeding risk is not as high as they thought, especially when used in conjunction with a stroke risk scheme.

The other thing to consider is that prescribing anticoagulants will always be a decision that is made with a great deal of patient involvement. So, tools like a stroke risk calculator or a bleeding risk calculator facilitate that discussion and help the patient understand the risks and benefits of therapy.

HN: What does the Anticoagulation Clinic at UCSF do, and how is this different from how anticoagulation is managed at other hospitals?

DR. FANG: Our anticoagulation clinic manages about 600 patients taking chronic anticoagulants. It’s staffed by nurse practitioners and pharmacists who are all trained in anticoagulant management and in our anticoagulation protocols. As the medical director, I’m the only physician who is part of this clinic, and I serve in more of a supervisory role in which I can provide clinical input where needed and help develop standardized protocols and practice patterns. Many of the anticoagulation clinics are built in similar ways.

In the past, much of the anticoagulation management was handled by individual practitioners, such as primary care physicians. But there was an increasing body of literature to support the use of anticoagulation clinics, so now many larger institutions have an anticoagulation management service and an anticoagulation clinic. Some may have physicians working there, but I think that the majority have an interdisciplinary team with pharmacists and nurse practitioners managing most of the patients.

HN: What’s the role of the hospitalist in anticoagulation management?

DR. FANG: Hospitalists pay quite a lot of attention to transitions of care. Attending on the medical service, I understand a little bit about both what people know and what they don’t know about the referral and transitions processes when moving someone to an outpatient anticoagulation clinic. I serve as a liaison and try to think of ways to smooth that transition.

HN: What are the future research areas that are ripe to explore in the anticoagulation field?

DR. FANG: One of the most exciting areas is the development of newer anticoagulants that do not require the frequent blood tests and monitoring that warfarin does. Right now, our anticoagulation clinic exists because warfarin is very challenging to manage and requires very frequent visits. There are newer anticoagulants such as dabigatran and rivaroxaban and several others that are in the pipeline that may obviate the need for warfarin and therefore for anticoagulation clinics.

We know these newer agents seem as good as, if not better than, warfarin in very controlled settings and clinical trials, but we don’t know how they work in the potentially sicker, more difficult to manage populations that we see in the real world. There are certain indications and certain comorbidities that should make clinicians really cautious about using these agents. For instance, we don’t know these agents would perform in older individuals or in those who have renal disease. It’s important to figure out how clinicians are prescribing and using these medications, who they are using them in, and whether the outcomes in the real world are as good as those we’ve seen in clinical trials.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Margaret Fang, the medical director of the Anticoagulation Clinic at the University of California, San Francisco, has spent the past several years studying ways to prevent hemorrhage in older Americans through proper anticoagulation therapy. As a member of the Kaiser Permanente of North California ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study Group, she is investigating thromboembolic and hemorrhagic outcomes among more than 13,000 atrial fibrillation patients. Most recently, she and her research collaborators developed and evaluated a new risk stratification scoring system to assess the likelihood of anticoagulant-related bleeding in atrial fibrillation patients. (J. Am. Coll. Cardiol. 2011; 58: 395-401).

In an interview with Hospitalist News, Dr. Fang explained some of the recent findings from the ATRIA Study Group and offered her views on the best role for hospitalists in assuring proper anticoagulation therapy.

Hospitalist News: In a recent study, your team evaluated a tool to assess the risk of bleeding in atrial fibrillation patients. How would that tool be used clinically?

DR. FANG: We developed a bleeding risk score called the ATRIA bleed score. It’s specifically designed to be used in patients who are taking anticoagulants. Our goal was to try to use clinical factors to help clinicians and patients estimate the risk of having a major bleeding event while taking an anticoagulant.

There are stroke risk–stratification schemes out there that I think are more widely used in patients who have atrial fibrillation. These are based on their clinical factors and can estimate their annual risk of stroke. Anticoagulants have complications of bleeding too, so it’s important to describe what we think a patient’s risk of bleeding is while on therapy. This score used five fairly easily available clinical factors. Based on whether patients have these risk factors or not, we can counsel them about what their likelihood of having a bleed is in a given year. The range can be as low as less than 1% to nearly 18% per year. Depending on where a patient falls in that risk spectrum and their estimated risk of stroke, you can then decide whether or not it’s worth proceeding with taking anticoagulants.

HN: Do clinicians tend to overestimate bleeding risk?

DR. FANG: I think so. If you look at practice patterns of whether patients with atrial fibrillation are prescribed anticoagulants or not, it shows that almost half of eligible patients are not taking anticoagulants. When you survey physicians as to whether that’s because of a knowledge deficit or something else that’s keeping them from prescribing anticoagulants, the dominant reason is that they think the patient has too high of a bleeding risk or it’s too hard to control or manage the anticoagulants for a given patient. Even though a lot of studies have shown that the consequences of having a stroke are much more severe than the consequences of having a bleed on therapy, a significant proportion of patients with atrial fibrillation are not prescribed anticoagulants.

HN: If the ATRIA bleed score were widely used, would there be more patients who could take advantage of anticoagulation therapy?

DR. FANG: By using this tool, clinicians can find not only the very high-risk patients, but also may be reassured that on average their patients have a lower risk of bleed than what they may have anticipated. They may find that the bleeding risk is not as high as they thought, especially when used in conjunction with a stroke risk scheme.

The other thing to consider is that prescribing anticoagulants will always be a decision that is made with a great deal of patient involvement. So, tools like a stroke risk calculator or a bleeding risk calculator facilitate that discussion and help the patient understand the risks and benefits of therapy.

HN: What does the Anticoagulation Clinic at UCSF do, and how is this different from how anticoagulation is managed at other hospitals?

DR. FANG: Our anticoagulation clinic manages about 600 patients taking chronic anticoagulants. It’s staffed by nurse practitioners and pharmacists who are all trained in anticoagulant management and in our anticoagulation protocols. As the medical director, I’m the only physician who is part of this clinic, and I serve in more of a supervisory role in which I can provide clinical input where needed and help develop standardized protocols and practice patterns. Many of the anticoagulation clinics are built in similar ways.

In the past, much of the anticoagulation management was handled by individual practitioners, such as primary care physicians. But there was an increasing body of literature to support the use of anticoagulation clinics, so now many larger institutions have an anticoagulation management service and an anticoagulation clinic. Some may have physicians working there, but I think that the majority have an interdisciplinary team with pharmacists and nurse practitioners managing most of the patients.

HN: What’s the role of the hospitalist in anticoagulation management?

DR. FANG: Hospitalists pay quite a lot of attention to transitions of care. Attending on the medical service, I understand a little bit about both what people know and what they don’t know about the referral and transitions processes when moving someone to an outpatient anticoagulation clinic. I serve as a liaison and try to think of ways to smooth that transition.

HN: What are the future research areas that are ripe to explore in the anticoagulation field?

DR. FANG: One of the most exciting areas is the development of newer anticoagulants that do not require the frequent blood tests and monitoring that warfarin does. Right now, our anticoagulation clinic exists because warfarin is very challenging to manage and requires very frequent visits. There are newer anticoagulants such as dabigatran and rivaroxaban and several others that are in the pipeline that may obviate the need for warfarin and therefore for anticoagulation clinics.

We know these newer agents seem as good as, if not better than, warfarin in very controlled settings and clinical trials, but we don’t know how they work in the potentially sicker, more difficult to manage populations that we see in the real world. There are certain indications and certain comorbidities that should make clinicians really cautious about using these agents. For instance, we don’t know these agents would perform in older individuals or in those who have renal disease. It’s important to figure out how clinicians are prescribing and using these medications, who they are using them in, and whether the outcomes in the real world are as good as those we’ve seen in clinical trials.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.