Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation

Derington, Catherine G.; Goodrich, Glenn K.; Clark, Nathan P.; Reynolds, Kristi; An, Jaejin; Witt, Daniel M.; Smith, David H.; O’Keeffe‐Rosetti, Maureen; Lang, D.; Ho, P. Michael; Cheetham, T. Craig; Comer, Angela C.; King, Jordan B.

doi:10.1001/jamanetworkopen.2023.21971

Cited by 3 publications

(1 citation statement)

References 31 publications

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“…[14][15][16] However, improvements in clinical outcomes have not yet been shown with these types of interventions. [17,18] It remains to be seen if different interventions and/or analyses will identify clinical benefits from stewardship activities aimed at improving on-label DOAC dosing in the same way clinical outcomes have improved with antithrombotic stewardship activities to reduce unnecessary aspirin use. [19] This article is protected by copyright.…”

Section: Manuscriptmentioning

confidence: 99%

Timing of Off-Label Dosing of Direct Oral Anticoagulants in Three Large Health Systems

Herron,

DeCamillo,

Kong

et al. 2024

Thromb Haemost

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Background: While direct oral anticoagulants (DOACs) may be viewed as simpler to manage then warfarin, they present their own unique management challenges resulting in frequent off-label dosing. It is unknown to what extent off-label dosing occurs when a patient is started on a DOAC versus later in their treatment. Objectives: We aimed to characterize when off-label DOAC dosing is occurring and to evaluate the effectiveness of prescribing oversight using a registry-based intervention. Methods: We evaluated data from the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry, a retrospective quality improvement process using data abstractors, from 2018 – 2022 on the number of “alerts” that are generated in response to dosing deviating from evidence-based guidelines. Results: Among a sample of 1,261 to 1,563 annual DOAC-treated patients in the MAQI2 registry, off-label dosing was relatively common. Over the 5-year period from 2018 through 2022, there were 735 total dosing alerts. Alerts occurred more frequently during a follow-up than at the time of initial prescribing, 69.0% (507) versus 31.0% (228) respectively. After initial review by quality improvement abstractors, 18.2% of alerts (134) resulted in contact to the prescriber. When the prescriber was contacted, it led to an intervention 74.6% of the time. The most common intervention was a change in DOAC dosing. Conclusions: This study demonstrates the benefit of DOAC prescribing oversight using a registry-based intervention to monitor for off-label dosing for the entirety of the time period a patient is prescribed DOAC as deviations in evidence-based prescribing occur frequently during the follow-up period

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Section: Manuscriptmentioning

confidence: 99%

Timing of Off-Label Dosing of Direct Oral Anticoagulants in Three Large Health Systems

Herron,

DeCamillo,

Kong

et al. 2024

Thromb Haemost

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The effect of pharmacist-led interventions on the appropriateness and clinical outcomes of anticoagulant therapy: a systematic review and meta-analysis

Kefale,

Peterson,

Mirkazemi

et al. 2024

European Heart Journal - Quality of Care and Clinical Outcomes

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Aim Although pharmacist-led interventions in anticoagulant (AC) therapy are widely accepted, there is a lack of evidence comparing their effectiveness to usual care in terms of AC therapy appropriateness and clinical outcomes. We aimed to estimate the comparative effectiveness of pharmacist-led interventions on the appropriateness and clinical outcomes of AC therapy. Methods and Results Adhering to the PRISMA guidelines, we searched PubMed, EMBASE, and Scopus databases to identify randomised controlled trials and quasi-experimental and cohort studies published between 2010 and 2023. A random-effects model was used to calculate pooled intervention effects. We assessed heterogeneity (using Higgins’ I2 and Cochran's Q) and publication bias (using Egger's test, the trim-and-fill method and visualisation of the funnel plot). In total, 35 studies involving 10 374 patients in the intervention groups and 11 840 in the control groups were included. The pharmacist-led interventions significantly improved the appropriateness of AC therapy (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 2.33–5.06, p < 0.01). They significantly decreased total bleeding (relative risk [RR]: 0.75, 95% CI: 0.58–0.96, p = 0.03) and hospitalisation or readmission (RR: 0.64, 95% CI: 0.41–0.99, P = 0.04). However, the impact of the pharmacist-led interventions on thromboembolic events (RR: 0.69, 95% CI: 0.46–1.02, p = 0.07) and mortality (RR: 0.76, 95% CI: 0.51–1.13, p = 0.17) were not significant. Conclusion Pharmacist-led interventions demonstrated superior outcomes in optimising AC therapy compared to usual care. Further research is needed to evaluate pharmacist-led interventions’ cost-effectiveness and long-term sustainability. PROSPERO registration number CRD42023487362.

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Pharmacist Use of a Population Management Dashboard for Safe Anticoagulant Prescribing: Evaluation of a Nationwide Implementation Effort

Barnes,

Chen,

Holleman

et al. 2024

JAHA

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Background Direct oral anticoagulants (DOACs) have complex dosing regimens and are often incorrectly prescribed. We evaluated a nationwide DOAC population management dashboard rollout whose purpose includes pharmacist review and correction of off‐label dosing prescriptions. Methods and Results Using data from Veterans Health Affairs, we identified all patients prescribed DOACs for atrial fibrillation or venous thromboembolism between August 2015 and December 2019. Sites were grouped on the basis of the timing of moderate‐high usage of the DOAC population management tool dashboard. Effectiveness was defined as the monthly rate of off‐label DOAC prescribing and the rate of clinical adverse events (bleeding, composite of stroke or venous thromboembolism). Implementation was evaluated as the percentage of off‐label DOAC prescriptions changed within 7 days. Among the 128 652 patients receiving DOAC therapy at 123 centers, between 6.9% and 8.6% had off‐label DOAC prescriptions. Adoption of the DOAC population management tool dashboard before July 2018 was associated with a decline in off‐label dosing prescriptions (8.7%–7.6%). Only 1 group demonstrated a significant reduction in monthly rates of bleeding following implementation. All sites experienced a reduction in the composite of venous thromboembolism or stroke following dashboard adoption. There was no difference in the implementation outcome of DOAC prescription change within 7 days in any of the adoption groups. Conclusions Early adoption of the DOAC population management tool dashboard was associated with decreased rates of off‐label DOAC dosing prescription and reduced bleeding. Following adoption of the DOAC population management tool dashboard, all sites experienced reductions in venous thromboembolism and stroke events.

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Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation

Cited by 3 publications

References 31 publications

Timing of Off-Label Dosing of Direct Oral Anticoagulants in Three Large Health Systems

Timing of Off-Label Dosing of Direct Oral Anticoagulants in Three Large Health Systems

The effect of pharmacist-led interventions on the appropriateness and clinical outcomes of anticoagulant therapy: a systematic review and meta-analysis

Pharmacist Use of a Population Management Dashboard for Safe Anticoagulant Prescribing: Evaluation of a Nationwide Implementation Effort

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