Drive Thru
Maria G. Tanzi, PharmD
A drive-through point-of-care international normalized ratio (INR) testing model in a rural community during the pandemic promoted patient engagement and achieved maintenance of INR time in therapeutic range (TTR) above the benchmark for anticoagulation management, according to recent data published in the January 2022 issue of the American Journal of Health-System Pharmacy.
As Courtney Farrell, MD, explains, outpatient clinics started to close in March 2020 and patients were afraid to go to labs to get their INR tested.
“We needed to develop a novel care model to ensure we maintained appropriate access to care for our patients,” said Farrell, who is medical director for the Centralized Anticoagulation Clinic for Dartmouth-Hitchcock Medical Center in Lebanon, NH, where the clinic model is based. “This drive-through INR testing option allowed our patients to feel safe getting their INR tested, helped maintain compliance with testing appointments, and the overall feedback was extremely positive, with patients loving this alternative testing option and wanting us to continue to offer this service.”
Determining the need and addressing it
Clinicians, including pharmacists, at the Centralized Anticoagulation Clinic at Dartmouth-Hitchcock Medical Center, which serves a rural population, noticed that the stay-at-home orders issued early on in the COVID-19 pandemic resulted in a decline in patient INR testing. Seeing the need to maintain routine INR testing, especially for those who were high-risk or were not maintained on a stable dose of warfarin, a drive-through point-of-care INR testing site opened within 5 days following issuance of the order.
The service was available from April 1, 2020, to May 15, 2020, and clinicians saw patients 4 days a week, with a total of 15 patients coming through the testing site each day. Patients were offered a 5-minute slot for their testing appointment. The staff completed 168 drive-through patient appointments in April and 84 in May. The availability of this service allowed the clinic to maintain stability in patient care, and the outcomes were positive. The TTR was 68% to 70% prior to the pandemic, and in April 2020, it remained stable at 70%. The TTR dropped slightly in May to 68% but rebounded in June to 71%.
Considerations
When considering developing a novel testing model such as this, Farrell noted that leadership buy-in and support up-front is essential.
The space and location to run such a clinic also needs to be well thought out. Farrell said their clinic parking lot got extremely busy, and this model may be challenging to implement if space is a limitation—as it might be in an urban area. The local weather is also a factor to consider, as CoaguChek monitors need to be operated in a temperature range of 59 °F to 90 °F. Since the outdoor temperature in New Hampshire during April was 40 °F, monitors were rotated and only outdoors for no more than 3 to 5 minutes at a time. A modified medical supply cart was also used to help protect equipment and supplies from the outdoor elements.
Additionally, staff was needed to run the drive-through testing and to follow up with phone consultations later in the day to discuss any warfarin dosage modifications. Another consideration is billing, as clinicians may be losing billable office visits to the drive-through visits. However, the drive-through visits could be billed as a telephone visit. Pharmacists are not currently considered billable providers and there may be a loss of revenue depending on the staff in the anticoagulation clinic.
Future opportunities
“This model can be applied even more broadly in the future as it appeals to a broad set of patients because of its ease of use,” said Farrell. “A drive-through clinic model offers additional opportunities for access to care for patients who have mobility disabilities and for many who appreciate the convenience.We need to think beyond the confines of a traditional clinic model.” ■
Tanzi is an employee of Incyte Corporation. The opinions expressed in this article are those of the author and do not represent the views of Incyte.