Anticoagulation stewardship: Descriptive analysis of a novel approach to appropriate anticoagulant prescription

Abstract

Background Anticoagulants are a leading cause of morbidity among hospitalized patients, with prescription errors commonly reported. Literature surrounding anticoagulation stewardship is scarce despite its documented effectiveness in the antimicrobial realm. Objective To determine the proportion of accepted recommendations on inappropriate anticoagulant prescriptions suggested by a multidisciplinary anticoagulation stewardship program (ASP). Methods We conducted a descriptive cohort study of hospitalized patients using therapeutic anticoagulation at a large Canadian tertiary care center between September 1, 2019, and February 28, 2020. A multidisciplinary ASP, composed of physicians and pharmacists, was implemented on June 1, 2019. Patient‐, anticoagulant‐, and admission‐related characteristics were collected. The primary outcome was the proportion of accepted ASP team recommendations by the prescribing team. Results A total of 381 patients were enrolled during the study period, resulting in 553 anticoagulant reviews (1.56 reviews/patient) by the ASP. The most common indications for anticoagulation were atrial fibrillation (n = 276, 72%) and venous thromboembolism (n = 84, 22%). Direct oral anticoagulants were most frequently prescribed (n = 253, 67%), followed by vitamin K antagonists (n = 88, 23%). Among the reviewed prescriptions, 355 of 553 (64%) generated a recommendation; 299 of 355 (84%) recommendations were accepted by the treating team. Dose adjustments were the leading category of recommendations (31%), followed by alerts regarding drug interactions (19%). Conclusion Inpatient anticoagulant prescriptions were optimized following recommendations by the ASP team. The most frequent types of prescription changes concerned dose adjustments and drug interactions. Further research is required to assess the effect of an ASP on clinical outcomes.

Drug-related problems associated with direct oral anticoagulants: an observational cross-sectional study of medical record review by pharmacists in a large teaching hospital

“…Our hospital practice to mandate all DOAC orders to be reviewed by pharmacists was similar to the hospital level safety surveillance implemented to oversee anticoagulant prescription under the Anticoagulation Stewardship program (ASP) described by Koolian et al. [ 37 ]. The ASP involved a dedicated team of physicians and clinical pharmacists who reviewed all anticoagulant prescriptions.…”

A cross-sectional study of appropriateness evaluation of anticoagulation therapy for inpatients with nonvalvular atrial fibrillation

“…In clinical practice, we intend to intervene to improve guideline-adherence for anticoagulation therapy. Since managing patients with AF is complex, an anticoagulation team, including physicians, clinical pharmacists, and nurses from multiple disciplines, is necessary ( Gebreyohannes et al, 2021 ; Koolian et al, 2022 ). Subsequently, for patients diagnosed with NVAF, the team could administer individualized anticoagulation regimens based on the patient’s age, liver function, kidney function, concomitant disease, concomitant drugs, and operation type, according to shared decision-making principles ( Supplementary Table S1 and Supplementary Figure S1 ).…”

Approaches to Precision‐based Anticoagulation management in the critically Ill

“…Note how long it has been since the initial VTE, the presence of previous events, or a hypercoagulable state to determine if anticoagulation even needs to continue. Assessment of anticoagulation needs might prevent erroneous re‐initiation of anticoagulation which is vital to the thrombosis stewardship process 38 . If a supratherapeutic level of the DOAC was observed, a good transition of care plan might consider discussion for reassessing the initial DOAC dose, presence of co‐morbidities or drug–drug interactions that may have led to the high level of anticoagulation, and subsequent long‐term anticoagulation plan.…”