Risk of clots, stroke from incorrect blood thinner dosing reduced using online dashboard

Direct oral anticoagulants are the most popular blood thinners, yet doctors commonly prescribe the wrong dose

September 16, 2024 12:17 PM

Jacob Dwyer, Justine Ross, Michigan Medicine

Doctors and pharmacists treating people with blood thinners can reduce the rate of inappropriate dosing — as well as blood clots and strokes that can result from it — using an electronic patient management system, a study suggests.

The online dashboard, developed by the United States Veterans Health Administration in 2016, was designed to highlight and optimize the treatment of patients with direct oral anticoagulants, or DOACs, the most commonly prescribed blood thinners.

Researchers led by Michigan Medicine used the tool to assess over 120,000 cases in which patients with atrial fibrillation or venous thromboembolism, blood clots in the veins, were treated with DOACs at 123 VA hospitals from mid-2015 through 2019.

They found that between 6.9 and 8.6% of patients received incorrect prescriptions for blood thinners.

Adoption of the electronic DOAC patient management tool led to a decline in off-label dosing of around 8%.

The rate of blood clots and stroke also declined at every hospital that implemented the monitoring tool.

Results are published in the Journal of the American Heart Association.

“While DOACs are lifesaving medications for patients with common thrombotic conditions, they can also cause serious harm when prescribed inappropriately,” said Geoffrey Barnes, M.D., M.Sc., first author and associate professor of cardiology-internal medicine at U-M 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.”

Direct oral anticoagulants can be incorrectly prescribed up to 20% of the time.

The two most prescribed DOACs are rivaroxaban (brand name Xarelto) and apixaban (brand name Eliquis.)

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

In Michigan, the Michigan Anticoagulation Quality Improvement Initiative, a multi-center 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.

“This study provides one of the largest and most impactful evaluations of an anticoagulation stewardship effort to show reduction in adverse clinical events,” Barnes said.

“Health systems and policymakers should consider investing in anticoagulation stewardship efforts that support pharmacists in reviewing and correcting off label direct oral anticoagulant dosing for the benefit of millions of patients who take these medications.”

Additional authors: Joshua Errickson, Ph.D., F. Jacob Seagull, Ph.D., Michael P. Dorsch, PharmD, M.S., Jeremy B. Sussman, M.D., M.S., all of University of Michigan, Charity Chen, M.S., and Rob Holleman, M.P.H., Sussman, all of the Ann Arbor VA Center for Clinical Management Research, Arthur L Allen, PharmD, CACP, of Veterans Affairs Salt Lake City Health Care System, and Patrick Spoutz, PharmD, BCPS, of Veterans Integrates Service Network 20.

Funding/disclosures: This project was funded by the Agency for Healthcare Research and Quality (AHRQ) through grant R18HS026874.

Support for MAQI² is provided by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program.

Although Blue Cross Blue Shield of Michigan and MAQI² work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.

Barnes consults for Pfizer, Bristol-Myers Squibb, Janssen, Bayer and AstraZeneca. He is on the Board of Directors for the Anticoagulation Forum.

Paper cited: “Pharmacist Use of a Population Management Dashboard for Safe Anticoagulant Prescribing: Evaluation of a Nation-wide Implementation Effort,” Journal of the American Heart Association. DOI: 10.1161/JAHA.124.035859

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