Correcting Inappropriate Prescribing of Direct Oral Anticoagulants: A Population Health Approach

Dawson, Taylor; DeCamillo, Deborah; Kong, Xiaowen; Shensky, Brian; Kaatz, Scott; Krol, Gregory D.; Ali, Mona A; Haymart, Brian; Froehlich, James B.; Barnes, Geoffrey D.

doi:10.1161/jaha.120.016949

Cited by 13 publications

(13 citation statements)

References 4 publications

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“…Inappropriate low doses are more frequent in Asia than in the Western countries because bleeding is more frequent in Asians than in non-Asians, and physicians may be inclined to avoid bleeding complications [17,18]. Off-label DOAC dosing has been reported to be more common among older patients, female patients, underweight patients, and those with chronic kidney disease, and our study had similar results [19].…”

Section: Discussionsupporting

confidence: 78%

Impact of Off-Label Under-Dose Direct Oral Anticoagulant on Coagulation and Fibrinolytic Markers in Patients with Atrial Fibrillation

Watanabe

Tachibana²,

Shinoda³

et al. 2022

SSRN Journal

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Section: Discussionsupporting

confidence: 78%

Impact of Off-Label Under-Dose Direct Oral Anticoagulant on Coagulation and Fibrinolytic Markers in Patients with Atrial Fibrillation

Watanabe

Tachibana²,

Shinoda³

et al. 2022

SSRN Journal

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“…Expanding ASPs to ambulatory populations could be of interest since a significant proportion of recommendations occurred at the time of admission, highlighting that inappropriate anticoagulant prescriptions are pervasive in the outpatient setting as previously reported 9,10 . In fact, a prior study noted off‐label dosing of DOACs in 9.4% of outpatients in a Michigan collaborative (Michigan Anticoagulation Improvement Initiative) and by means of a programmed alert prompting direct contact with the prescribing physician, meaningful prescription changes were made in 63% of cases 22 . There is also emergence of technologies to aid and support oversight of DOAC prescription and compliance with best practices 23 …”

Section: Discussionmentioning

confidence: 87%

“…Perlman et al 21 contact with the prescribing physician, meaningful prescription changes were made in 63% of cases. 22 There is also emergence of technologies to aid and support oversight of DOAC prescription and compliance with best practices. 23 Recent prospective studies have analyzed the impact of anticoagulation stewardship on adherence to guidelines and on clinical outcomes of safety and efficacy.…”

Section: Discussionmentioning

confidence: 99%

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

Koolian

Wiseman

Mantzanis

et al. 2022

Research and Practice in Thrombosis and Haemostasis

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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.

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“…While safer and dramatically simpler to dose and monitor than warfarin, accurate DOAC prescribing is still complicated and adverse events due to incorrect dosing remain relatively common. In fact, multiple studies have identified that as many as 1 in 7 patients have inappropriate DOAC prescriptions [ 9 – 12 ]. Common prescribing issues include failure to adjust medication dosing appropriately for kidney or liver disease, failure to recognize potential drug-drug interactions, and failure to adjust dosing for different clinical indications as appropriate.…”

Section: Introductionmentioning

confidence: 99%

Implementing an electronic health record dashboard for safe anticoagulant management: learning from qualitative interviews with existing and potential users to develop an implementation process

Barnes

Sippola

Ranusch

et al. 2022

Implement Sci Commun

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Background Facilitating appropriate care delivery using electronic health record (digital health) tools is increasing. However, frequently used determinants frameworks seldom address key barriers for technology-associated implementation. Methods Semi-structured interviews were conducted in two contexts: the national Veterans Health Affairs (VA) following implementation of an electronic dashboard, a population health tool, and the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) prior to implementation of a similar electronic dashboard. The dashboard is designed for pharmacist or nurse use to monitor safe outpatient anticoagulant prescribing by physicians and other clinicians We performed rapid qualitative inquiry analysis and selected implementation strategies. Through a stakeholder focus group session, we selected implementation strategies to address determinants and facilitate implementation in the MAQI2 sites. Results Among 45 interviewees (32 in VA, 13 in MAQI2), we identified five key determinants of implementation success: (1) clinician authority and autonomy, (2) clinician self-identity and job satisfaction, (3) documentation and administrative needs, (4) staffing and work schedule, and (5) integration with existing information systems. Key differences between the two contexts included concerns about information technology support and prioritization within MAQI2 (prior to implementation) but not VA (after implementation) and concerns about authority and autonomy that differed between the VA (higher baseline levels, more concerns) and MAQI2 (lower baseline levels, less concern). Conclusions The successful implementation of electronic health record tools requires unique considerations that differ from other types of implementation, must account for the status of implementation, and should address the effects of the tool deployment on clinical staff authority and autonomy. Interviewing both post-implementation and pre-implementation users can provide a robust understanding of implementation determinants.

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Correcting Inappropriate Prescribing of Direct Oral Anticoagulants: A Population Health Approach

Cited by 13 publications

References 4 publications

Impact of Off-Label Under-Dose Direct Oral Anticoagulant on Coagulation and Fibrinolytic Markers in Patients with Atrial Fibrillation

Impact of Off-Label Under-Dose Direct Oral Anticoagulant on Coagulation and Fibrinolytic Markers in Patients with Atrial Fibrillation

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

Implementing an electronic health record dashboard for safe anticoagulant management: learning from qualitative interviews with existing and potential users to develop an implementation process

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