Population Management Tool Reduces Adverse Events of DOACs

The inappropriate use of direct-acting oral anticoagulants (DOACs) increases the risk of adverse events (AEs), but use of a population health management tool (PMT) may reduce AEs by identifying questionable prescribing practices early.

A recent study in Journal of Thrombosis and Thrombolysis sought to determine if the use of a PMT improved the quality of DOAC dosing compared with traditional delivery approaches by analyzing the Veterans Health Administration (VHA) PMT for monitoring patients on DOACs.

Though DOACs do not require therapeutic monitoring, they are considered high-risk medications with specified dosing related to both indication and patient-specific factors. Off-label dosing of DOACs has been connected with both bleeding and thrombotic events, so given these potential risks there is great value in assessing the impact of a DOAC PMT on dosing.

This retrospective, cross-sectional study was conducted with existing data pulled from the VHA Corporate Data Warehouse across 40 VHA medical centers. The 20 medical centers in the “lowest quintile,” defined as the frequency of PMT report executions over the prior 365 days, were classified as the standard of care (SOC) group while the remaining 20 medical centers were classified as the “PMT User Group.” The latter accessed the tool between 5231 and 19,585 times per year.

In the PMT user medical centers, there were 47,491 DOAC patients analyzed while the SOC centers analyzed data from 27,288 DOAC patients. The authors found that within the 20 PMT user medical centers, 25% (n = 5) were classified as “high” questionable dosage rates and 75% (n = 15) were classified as “low” questionable dosage rates. Within the SOC group, the opposite was found: 75% (n = 15) were classified as “high” questionable dosage rates while 25% (n = 5) were “low” questionable dosage rates.

Though the findings were statistically significant (P = .002), they were not found to be clinically significant due to the relatively few absolute differences between groups with respect to age, weight, creatinine clearance, disease indication, and medication prescribing rates. Importantly, the PMT user group was determined to have a significantly lower questionable dosage rate (13.2%) compared with the SOC group (17.5%).

The most pronounced impact was seen among the subgroup of patients with atrial fibrillation (AF). The tool was associated with a 5.1% absolute reduction in questionable dosing rates in AF. These questionable dosing rates were also reduced through the use of the tool in the subgroups of patients taking apixaban and dabigatran, as well patients with AF plus venous thrombolism.

This finding provides reason to believe that more widespread adoption of the tool would meaningfully improve patient outcomes given the risks of DOAC dosages, according to the authors.

“Fully evaluating the impact of PMTs on clinical outcomes is still necessary,” they concluded. “For the DOAC PMT specifically, future research studies could include a prospective study evaluating changes in dosing, serious bleeding, thromboembolic events, hospitalizations, and mortality before and after transition to using a DOAC PMT.”

Reference

Rossier C, Spoutz P, Schaefer M, Allen A, Patterson M. Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management. J Thromb Thrombolysis. Published online November 22, 2020. doi:10.1007/s11239-020-02341-y