1. National Institute for Public Health and the Environment Cooperation in oral anticoagulant therapy needs and barriers to improve H. Drewes, M. Lambooij, C. Baan, B. Meijboom, G. Westert

2. National Institute for Public Health and the Environment Oral anticoagulant therapy (OAT) OAT reduce the risk of thrombosis Challenge: balance the risk between haemoraghe and thrombosis Balance influenced by many factors -e.g. co-medication, fever, food intake, doses advices Balance influenced by many health care professionals  Cooperation needed No. of patients in NL: 350.000 25% of avoidable hospitalizations related to OAT

3. National Institute for Public Health and the Environment Anticoagulant clinics (AC) In Netherlands 59 anticoagulant clinics (ACs): monitoring patients and advice on medication use ACs provide better patient outcomes than routine medical care However: Substantial differences in patient outcomes between ACs Differences in cooperation between ACs -e.g. multidisciplinary protocols, structural meetings etc.

4. National Institute for Public Health and the Environment Research questions To identify the bottlenecks for cooperation To identify facilitators/solutions to improve cooperation To identify barriers for improvement the cooperation

5. National Institute for Public Health and the Environment Methods Data -23 specialised anticoagulant clinics (AC) -selective purposive sampling based on 3 characteristics: the number of patients the organisation structure quality of care considering the patient outcomes -68 semi-structured interviews

6. National Institute for Public Health and the Environment Methods Data analysis -Fully transcriped interviews open coded by two authors -data structured with Chronic Care Model

7. National Institute for Public Health and the Environment Experienced bottlenecks Lack of knowledge: Although a patient was stable with 6 tablets a day, he was discharged with a doses of 4, 2, 2, for the following three days. [..]You could say, ask the patient what he usually used. Lack of consensus between professionals We don’t agree with the policy of one of our hospitals, but couldn’t convince them. We have to follow their advice; otherwise patients are send home without an operation. Limited information exchange Really, it is sometime a struggle to get the information about a hospital admission.

8. National Institute for Public Health and the Environment Experienced bottlenecks Bottlenecks leads to: - Suboptimal OAT - Inefficacy due to time-consuming effort to correct mistakes

9. National Institute for Public Health and the Environment Preferred initiatives

10. National Institute for Public Health and the Environment Major Experienced barriers Lack of motivation -professionals not motivated to learn from ACs (no knowledge) -don’t accept their view (no consensus) -are not motivated to inform the ACs (no information). Lack of time Lack of resources/ materials

11. National Institute for Public Health and the Environment Conclusions Bottlenecks of coordination are information exchange, lack of knowledge, lack of consensus Decision support is prerequisite for the succes of AC management as it improves knowledge Crucial to succesfully implement decision support seems to be informal coordination/contact