Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), affects one to two per one thousand persons annually in the US. Treatment of VTE consists of anticoagulation therapy, and evidence supports treating patients with low-risk VTEs as outpatients. Novel oral agents such as rivaroxaban, an oral factor Xa inhibitor, require less monitoring than traditional anticoagulation with warfarin. As an expansion to pharmacy services at a metropolitan, academic health center, pharmacists are now independently managing a VTE clinic, also known as the clot clinic, which exclusively uses rivaroxaban for the outpatient treatment of low-risk DVTs and PEs.
Purpose: To describe the implementation and work flow of a pharmacist-managed clinic for the outpatient treatment of VTEs using rivaroxaban.
Description: The clot clinic was initiated by emergency department (ED) physicians as a fellowship research project aimed to treat patients with low-risk VTEs as outpatients. Patients diagnosed with a low-risk VTE in the ED are prescribed rivaroxaban and sent home with a clot clinic appointment scheduled between two to five weeks of their initial diagnosis. In anticipation of the fellows’ graduation, these physicians engaged the pharmacy department for assistance with transitioning the clinic’s management to pharmacists. During a six month overlap period, pharmacists shadowed, trained, and created a collaborative practice agreement outlining specific protocols and medication management procedures that was later approved by hospital leadership.
Prior to each clinic appointment, the pharmacist reviews the patient’s electronic medical record to analyze VTE diagnosis, laboratory data, and medications. Laboratory tests including basic metabolic panel (BMP), PT/INR, complete blood count (CBC), D-dimer, and/or anti-Xa levels can be ordered at the discretion of the pharmacist. During the visit, the pharmacist asks a series of questions regarding current symptoms and performs a focused physical exam to evaluate the patient’s progress on rivaroxaban therapy. Patients are counseled on laboratory results, medication use, adherence, side effects, drug interactions, lifestyle modifications, smoking cessation, and other issues related to rivaroxaban as they arise. Adjustments to duration of therapy are based on location and nature of clot, patient’s personal history of thrombosis, and in some cases, D-dimer concentrations. A unique contribution to clinic services provided by the pharmacists includes assistance with navigating insurance-related issues such as prior authorizations, patient assistance programs, and other sources of sustainable funding to ensure completion of therapy.
Conclusions: The clot clinic was established to manage VTEs using rivaroxaban in the outpatient setting. The clinic successfully transitioned from physician to pharmacist management and next steps include evaluating clot clinic patient outcomes.