Transitioning Eligible Patients from Warfarin to a Direct Oral Anticoagulant: A Prospective Quality Improvement Study
Authors: Wang Kevin Y , Syed Noreen , Fanous Matt , Islam Mohammed , Liu Michael , Nguyen Duc , Mahmood Eitesaz , Ehrlich Jason C 
Published: November 2021

Abstract
Background:
Direct oral anticoagulants (DOACs) are rapidly replacing alternative agents as the preferred choice for anticoagulation. With extended time on the market and expanded guidelines for indications for use, they are now more accessible and affordable. Qualifying patients previously treated with warfarin for long-term anticoagulation may benefit from transitioning to a DOAC. In this prospective quality improvement study, we seek to identify eligible patients and transition them from warfarin to DOAC via shared decision-making and a multidisciplinary approach. Additionally, we will assess changes in quality of life (QOL) through a validated survey.
Methods:
Identify patients currently on warfarin who are eligible for transition to a DOAC. Eligibility criteria include patients with age &gt;18 years old. Exclusion criteria includes pregnancy, BMI &gt;50 kg/m2, CrCl &lt;15 L/min, patients receiving anticoagulation for APLS or for mechanical heart valves. With the aid of our pharmacy team, we then ensure long-term medication affordability prior to transition. Eligible patients complete a QOL survey pre-transition and 3 months post-transition. The QOL survey is the validated Anti-Clot Treatment Scale (ACTS), which is a 15 question survey which includes a Burden scale composed of 12 questions and a Benefit scale composed of 3 questions and each question is scored from 1 to 5 (1=not at all, 2=a little, 3=moderately, 4=quite a bit, 5=extremely). The Burden scale is reverse scored so that higher ACTS Burden scores indicate greater satisfaction for a score range of 12-60. The Benefit scale is scored conventionally for a score range of 3-15. The Total score is calculated by the addition of the Burden scale and Benefit scale for a score range of 15-75. Paired T-tests were conducted on the Burden scale, Benefit scale, and Total score using GraphPad Prism version 7 (GraphPad Software, La Jolla, CA). P-values were two-tailed, with a p&lt;0.05 considered statistically significant.
Results:
25 patients out of 60 were identified as eligible for DOAC transition. Total score, Burden scale, and Benefit scale mean values were 49.5, 39.5, 10 for warfarin and 66.8, 53.5, and 13.3 for DOAC, respectively. Preliminary conducted analysis revealed statistically significant improvements in Total, Burden, and Benefit scores with p-values of 0.0046, 0.0075, and 0.0319 and mean improvements of 17.3, 14, and 3.25, respectively.
Conclusion:
Transitioning patients from warfarin to a DOAC has been found to decrease both patients' sense of burden while also improving their sense of benefit, as evidenced by the QOL survey analysis. Transitioning patients from warfarin to a DOAC has the potential to decrease need for routine INR monitoring, dietary limitations, and fewer drug interactions. Additionally, it improves patient satisfaction with their healthcare and reduces utilization of healthcare resources.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.