Clinical pharmacists and nurses' perceptions on implementing anticoagulation therapy recommendations for the frail elderly: An exploratory study based on psychological theory

Abstract

Background: Stroke is a leading cause of mortality and disability in Canada. Persons with atrial fibrillation (AF) have a five-fold increased risk of developing a stroke. AF is a significant contributor to stroke at all ages and the prevalence of AF is rising with age. In Canada, the treatment for persons with chronic non-valvular AF is to provide long-term oral anticoagulation therapy (OAT) with warfarin, which has been shown to reduce the risk of stroke by two-thirds. Routine care administered by physicians is often inconvenient because it requires regular doctor visits, a time lag between laboratory testing and follow ups, and frequent ad-hoc dose adjustments to prevent adverse outcomes. These challenges often contribute to poor OAT management to result in an increased risk of bleeding and clotting. These risks are further complicated for people with AF who are older, frail, have multiple co-morbidities and polypharmacy. The solution is to offset these complications through optimizing delivery of OAT using anticoagulation management services (AMS). Research has shown that pharmacist or nurse-led AMS are comparable or better than physician-led care in terms of cost-effectiveness and patient outcomes. Despite this, AMS clinics need to establish a more integrated approach for the optimal delivery of OAT management. Published and available in the literature are clinical recommendations by Garcia et al. (2008) on how to optimize OAT delivery in outpatient AMS settings; however, the deliberate implementation of the guideline remains an issue. Objectives: To address the problem in the context of a frail, aging population, this study explores the pharmacists and nurses’ perceptions of implementing Garcia et al.’s (2008) clinical guideline for optimal OAT management in existing specialized AMS clinics within the Waterloo-Wellington Local Health Integration Network (WWLHIN) community. Specifically, this study uses Michie et al.’s (2005) psychological theory to explore (1) how existing intrinsic and extrinsic factors hindered or supported; and (2) how behavioural changes facilitate the implementation of Garcia et al.’s (2008) clinical guideline for optimal OAT management. Methods: This study used a qualitative, explorative design with a purposive sample of clinicians (key informants) working in AMS clinics within the WWLHIN community: Waterloo-Kitchener, Cambridge and Guelph. Key informants were recruited from family health teams (FHTs) and community pharmacies, and sampled until the point of saturation. Semi-structured interview questions covered 12 domains under a theoretical lens, Michie et al.’s (2005) psychological theory: (1) Knowledge, (2) Skills, (3) Social/professional role and identity, (4) Beliefs about capabilities, (5) Beliefs about consequences, (6) Motivation and goals, (7) Memory, attention and decision processes, (8) Environmental context and resources, (9) Social influences, (10) Emotion, (11) Behavioural regulation, and (12) Nature of the behaviours. These 12 domains represent the relevant factors that influence the implementation of clinical guidelines. Garcia et al. (2008) published a clinical guideline with 9 key recommendations for optimal delivery of OAT management in outpatient AMS settings: (1) Qualifications of Personnel, (2) Supervision, (3) Care Management and Coordination, (4) Documentation, (5) Patient Education, (6) Patient Selection and Assessment, (7) Laboratory Monitoring, (8) Initiation and Stabilization of Warfarin Therapy, and (9) Maintenance of Therapy. Interviews averaged 40 minutes per key informant and produced a total of 108 pages of transcript. Data were coded and analyzed using NVIVO Pro 11 based on the theoretical framework. Results: There were six clinics that participated in the study: three family health teams and three community pharmacies with AMS clinics. Within these six clinics, there were a total of eight key informants: six pharmacists and two registered nurses. The majority of key informants were from the Kitchener-Waterloo region with more than one-year experience in OAT in the community setting. There were five salient themes in the results: (1) Inadequate reimbursement for logistical operation of AMS clinics; (2) Clinicians’ awareness of how to apply knowledge to support practices; (3) Tailored organizational supports for the frail elderly; (4) Engagement of efforts to improve interprofessional communication and collaboration; and (5) Use of compatible software platforms for documentation. Theme 1 hindered, theme 2 and 3 supported, and theme 4 and 5 facilitate the implementation of Garcia et al.’s (2008) clinical guideline for the optimal delivery of OAT management in participating AMS clinics. Discussion: In determining that inadequate funding was a key barrier to implementation, the finding suggests that if key informants cannot cover their costs, they cannot offer optimal OAT management per the clinical guideline. There is currently no coverage of services and materials for OAT management by pharmacists and nurses in Canada, except for Quebec. Instead, Ontario’s pharmacists in community AMS clinics use other means to recover costs for OAT management services. In light of these findings, there needs to be appropriate funding for community AMS to continue their valuable services, otherwise OAT management may fall back to usual care and block optimal practices. Other factors affecting implementation are awareness of how to apply each recommendation of the clinical guideline to support practice and tailored organizational supports for the frail elderly. Although there was general awareness of the recommendations, one exception was the finding that suggests that key informants relied on an incomplete frailty assessment; this finding reflected other work showing that clinicians tend to diagnose frailty syndrome based on chronological age rather than biological age. Furthermore, other work corroborated the finding that tailored organizational supports for the frail elderly, such as physical tools, face-to-face interactions and home visits, enabled the implementation of the clinical guideline via improving medication adherence and monitoring of other health issues. In addition, other studies supported the finding that clinicians should engage in interprofessional communication and collaboration, especially during care transitions to facilitate optimal practices. One strategy was for nurse navigators to act as the focal point of contact for seamless care transitions, but existing pharmacists and nurses can also expand their scope of practice to methodically provide continuity of care and coordination of services in community-based AMS settings. Other work also supported the finding that social networking with experts in the local and wider regions facilitated optimal practices through maintaining competencies and gaining new knowledge. Another facilitator of optimal OAT management was to use compatible software platforms for standardized OAT documentation to integrate a systematic approach to management. However, the selection of an anticoagulation software program is complicated with many considerations, depending on individual clinic’s needs. There needs to be further investigation on the limited literature on the implications of using compatible software platforms for standardized documentation of OAT management. Conclusion: Linking key themes to the domains of Michie et al.’s (2005) psychological theory that influenced the implementation of the clinical guideline: (1) Inadequate reimbursement for logistical operation of AMS clinics was an environmental constraint (domain #8); (2) Clinicians’ awareness of how to apply knowledge to support practices was having the knowledge and skills (domains #1 and 2); (3) Tailored organizational supports for the frail elderly were environmental resources within their context (domain #8); (4) Engagement of efforts to improve interprofessional communication and collaboration was using social influences to prompt behavioural changes (domains #9 and 12); and (5) Use of compatible software platforms for documentation was a proposed system to change the nature of behaviours related to tracking and recording anticoagulation data (domain #12). Using the underlying theory, these key themes represent important factors for the deliberate implementation of the clinical guideline for optimizing delivery of OAT management. Insights on how various factors affect the implementation the clinical guideline can help key stakeholders scale up efforts for a broader, more uniform approach to optimal OAT management for a frail, elderly population.