key: cord-0813076-3w3cw4tu authors: Zobeck, Bryan; Carson, Erin; MacDowell, Martin; Hunt, Aaron; Reeder, Austin title: Appointment attendance and patient perception of drive‐up INR testing in a rural anticoagulation clinic during the COVID‐19 pandemic date: 2021-01-20 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1390 sha: 62d393dc081cbad652c69bff4d58fcaae633c86e doc_id: 813076 cord_uid: 3w3cw4tu INTRODUCTION: The Anticoagulation Forum and Centers for Disease Control and Prevention (CDC) recommend drive‐up international normalized ratio (INR) testing to combat INR non‐adherence and increase safety during the coronavirus disease 2019 (COVID‐19) pandemic. Patient perceptions and impact on attendance have not been studied. OBJECTIVE: To assess appointment volume and patient perception after initiation of drive‐up INR testing in a rural pharmacist‐managed anticoagulation clinic. METHODS: This cross‐sectional cohort survey study offered each patient attending the anticoagulation clinic via drive‐up or in‐office visit a survey between May 27 and July 2, 2020. Patients testing off‐site were excluded. Study end points included monthly patient volume, visit type preference, testing barriers, desired drive‐up duration, and overall clinic satisfaction. Clinic appointment volume from October 2019 to June 2020 was collected retrospectively through a schedule review. RESULTS: Sixty‐four (80%) of 80 surveys offered were completed: 46.6% of respondents preferred drive‐up testing, 26.7% indifferent, and 26.7% preferred in‐office visits; 38.7% of respondents indicated a greater likelihood of continuing routine INR monitoring via drive‐up testing. Of the respondents completing the survey curbside, 46% and 27% of respondents identified reduced COVID‐19 transmission risk and ease of transportation as benefits of drive‐up INR testing, respectively. March and April clinic volumes were 19% and 22% below average, respectively, returning to baseline after drive‐up testing was implemented. Clinic rating before and after drive‐up testing remained high at 2.75 on a scale of 0‐3. While infection risk was identified as the biggest barrier to care by 32.8% of respondents, 59.3% of all respondents wanted drive‐up testing to continue indefinitely. CONCLUSIONS: Drive‐up INR testing improves patient attendance during the COVID‐19 pandemic. Patient perception of drive‐up testing is positive. About 46% of respondents preferred drive‐up INR testing with telehealth follow‐up and 59.3% of respondents want drive‐up testing to continue indefinitely, which suggests this approach to INR testing as a potential method to allay barriers to routine monitoring beyond the scope of the pandemic. approach to INR testing as a potential method to allay barriers to routine monitoring beyond the scope of the pandemic. coronavirus, COVID-19, international normalized ratio, pharmacists, telemedicine, warfarin It is well documented that routine international normalized ratio (INR) monitoring is a critical component of safe and effective warfarin management. [1] [2] [3] Data from the IN-RANGE trial suggest that as many as 40% of patients have significant poor adherence, and that poor adherence is associated with double the rate of out-of-range INRs. 4 The correlation of poor time in therapeutic range and poor outcomes is well established. [1] [2] [3] However, routine monitoring typically requires regular contact with the health system. During the coronavirus disease 2019 (COVID-19) pandemic, it has been documented that patients are avoiding health care in order to maintain social distancing and reduce potential virus exposure. 5 The National Cardiac Societies, the Anticoagulation Forum, and the Centers for Disease Control and Prevention (CDC) recommend drive-up INR testing with telehealth assessment and follow-up as a method to continue routine monitoring with significantly less potential for virus exposure. [6] [7] [8] Several papers present broad strategies to employ telehealth and social distancing while continuing chronic care management, including anticoagulation management. [9] [10] [11] Drawing inspiration from these sources, the clinic described in this paper altered its model of care to include an alternative option of drive-up INR testing. This model combines drive-up INR testing with phone-based anticoagulation management. At this clinic, patients may opt for this model or traditional, inoffice visits based on personal preference. As with many of our adaptions to the novel and ever-changing The primary objective was to assess patient perceptions of drive-up INR testing with telehealth assessment and follow-up during the COVID-19 pandemic. Secondary objectives included determining if drive-up INR testing impacts patient attendance at routine INR monitoring appointments, measuring overall clinic satisfaction, and establishing data on barriers to care other than those associated with COVID-19. Patients presenting to either traditional, in-office care or drive-up INR testing between the dates of May 26 and July 2, 2020 were provided a paper survey (Supporting Information). Patients were instructed to complete the survey prior to receiving INR testing. Results were collected anonymously. Demographic data, including age and sex, were collected via chart review immediately as each patient completed the survey. Once patients completed the survey, demographics were marked by clinic staff and the survey was placed in a folder without any unique identifiers to ensure survey and patient anonymity. On average, the survey took 2 to 3 minutes to complete. No guidance was provided to patients as to how to complete the survey. Patients were only surveyed once, even if they were seen in the clinic multiple times during the survey period. If a patient declined a survey, they were offered the survey again at subsequent visits. The survey addressed: 1. Preference of visit type. 8. Avoidance of seeking medical care due to the COVID-19 pandemic. The medical record was retrospectively analyzed to determine appointment volumes, unique patient volumes, and TTR to determine if compliance with routine monitoring was impacted by the COVID-19 pandemic and/or by drive-up INR testing. Individual appointments were counted to determine appointment volume and individual patients were counted to determine unique patient volume. Rates prior to the pandemic and during the survey period were compared. Frequency distributions were done for each of the study variables using IBM SPSS Statistics for Windows, version 24 (IBM Corp., Armonk, New York). Paired t-tests were used to determine differences between a survey respondent's rating of the clinic before and after the start of drive-up testing. Due to non-normal distribution of values, Mann-Whitney nonparametric tests were used to assess the difference in clinic ratings between patients who were seen curbside compared with face-to-face appointments. (Table 2 ). Overall, rating of the clinic both before and after drive-up INR test- There was no statistically significant change in TTR between these two quarters. Outcomes in a warfarin-treated population with atrial fibrillation Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: A systematic review The influence of patient adherence on anticoagulation control with warfarin: Results from the International Normalized Ratio Adherence and Genetics (IN-RANGE) Study Optimising secondary prevention and cardiac rehabilitation for atherosclerotic cardiovascular disease during the COVID-19 pandemic: A position statement from the Cardiac Society of Australia and New Zealand (CSANZ) Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: Interim clinical guidance from the anticoagulation forum Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Managing Anticoagulation During the COVID-19 Pandemic. Frequently Asked Questions Management of outpatient warfarin therapy amid COVID-19 pandemic: A practical guide Managing anticoagulation in the COVID-19 era between lockdown and reopening phases Analysis of SARS-CoV-2 screening clinic (including drive-through system) data at a single university hospital in South Korea from 27 Illinois department of public health. COVID-19 in Illinois Lee county health department. Lee county COVID-19 daily update County Health Indicators CHNA Report, available at engagementnetwork. org (accessed Appointment attendance and patient perception of drive-up INR testing in a rural anticoagulation clinic during the COVID-19 pandemic The authors declare no conflicts of interest. https://orcid.org/0000-0002-1686-4239