Ann Arbor, MI—As many as 8.6% of patients are being prescribed incorrect dosages of DOACs, according to a new study that suggested using an electronic patient management system can help resolve that problem.

University of Michigan–led researchers pointed out that inappropriate dosing can result in blood clots and strokes. That is why they sought to access the benefit of an online dashboard developed by the United States Veterans Health Administration (VHA) in 2016. The tool was designed to highlight and optimize the treatment of patients with DOACs—the most commonly prescribed blood thinners.

The study team assessed more than 120,000 cases in which patients with atrial fibrillation or venous thromboembolism (VTE), blood clots in the veins, and who were treated with DOACs at 123 Veterans’ Affairs hospitals from mid-2015 through 2019.

The results published in the Journal of the American Heart Association indicate that between 6.9% and 8.6% of patients received incorrect prescriptions for blood thinners but that the electronic DOAC patient management tool led to a decline in off-label dosing of around 8%.

“While DOACs are lifesaving medications for patients with common thrombotic conditions, they can also cause serious harm when prescribed inappropriately,” said first author Geoffrey Barnes, MD, MSc, associate professor of cardiology-internal medicine at University of Michigan Medical School.

“Not only does our study show how commonly off-label dosing of DOACs occurs, but it highlights that utilizing this DOAC population health management tool can reduce that rate of inappropriate dosing as well as downstream complications, such as stroke and clotting,” Dr. Barnes added.

“Direct oral anticoagulants (DOACs) have complex dosing regimens and are often incorrectly prescribed,” the researchers pointed out. “We evaluated a nationwide DOAC population management dashboard rollout whose purpose includes pharmacist review and correction of off-label dosing prescriptions.”

The researchers used data from VHA to identify all patients prescribed DOACs for atrial fibrillation or VTE between August 2015 and December 2019.

Among the 128,652 patients receiving DOAC therapy at 123 centers, the researchers identified 6.9% to 8.6% who had off-label DOAC prescriptions. They found that 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 one group demonstrated a significant reduction in monthly rates of bleeding following implementation, although all sites experienced a reduction in the composite of VTE or stroke following dashboard adoption.

“Early adoption of the DOAC population management tool dashboard was associated with decreased rates of off-label DOAC dosing prescription and reduced bleeding,” the authors concluded. “Following adoption of the DOAC population management tool dashboard, all sites experienced reductions in venous thromboembolism and stroke events.”

The researchers added that DOACs are now the leading cause of adverse drug events in U.S. emergency departments, which is likely because of both the complexities in DOAC prescribing and the rapid growth in overall DOAC use. The two most prescribed DOACs are rivaroxaban (brand name Xarelto) and apixaban (brand name Eliquis).

The study advised how pharmacists at each VHA system use this DOAC PMT dashboard to review patient charts and quickly correct any off-label prescriptions. “Adoption and regular use of the PMT within VHA rapidly became near universal by 2019,” the study noted. “In many cases, pharmacists have replaced traditional visits with ‘Dashboard Clinics’ that focus entirely on patients with active ‘flags.’ One important type of’ flag’ addressed in these ‘Dashboard Clinics’ indicates possible off-label or incorrect DOAC dosing prescriptions.”

The Michigan Anticoagulation Quality Improvement Initiative, a multicenter collaborative of statewide hospitals, built a similar dashboard using the Epic electronic health record. Five hospitals across the state currently use that system, including University of Michigan Health.

The researchers suggested that health systems and policymakers “should consider investing in anticoagulation stewardship efforts that support pharmacists in reviewing and correcting off-label direct oral anticoagulant dosing.”

The sites that used the system the longest demonstrated a more significant decline in inappropriate prescribing.

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