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Health Services Research & Development

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Improving the Safe Use of Direct Oral Anticoagulants for Veterans

June 30, 2021


Takeaway: The Direct Oral Anticoagulants (DOAC) Dashboard is a population health management tool that is accessible at all 146 VA facilities to evaluate their clinical practice and anticoagulation programs. The DOAC Dashboard has been implemented (utilized) at 130 (89%) VA healthcare sites. It is in the process of being implemented at the remaining 16 (11%) VA sites. Altogether, more than 2,794 VA staff have been trained and/or currently use it. The DOAC Dashboard has served 277,826 Veterans.

Relatively new medications, direct oral anticoagulants (DOACs) include dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and betrixaban (Bevyxxa).

Use of direct oral anticoagulants (DOAC) is rapidly growing for the prevention and treatment of several cardiovascular conditions (i.e., atrial fibrillation and venous thromboembolism). With the increased use of DOACs, clinicians must make complex decisions regarding which DOAC to use, the duration of treatment, dosing, and use in special populations. For example, dosing recommendations differ for the DOACs based on indication, patient’s concurrent conditions, and metabolic function, which leads to incorrect dosing of these medications and puts patients at risk of adverse drug events. When DOACs are used inappropriately (over-dosing, under-dosing, and dosing based on the wrong indication), patients are at an increased risk for bleeding and thrombotic/stroke complications. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR) [Valencia et al., 2019; Rossier et al., 2020; Barnes et al., 2020; Allen AL, Lucas J, Parra D, Spoutz P, Kibert JL 2nd, Ragheb B, Chia L, Sipe A. Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants. J Am Heart Assoc. 2021 Dec 21;10(24):e022758. doi:10.1161/JAHA.121.022758. Epub 2021 Nov 19.PMID: 34796718].

In addition to the DOAC dashboard, four other national VA dashboards are currently in development:

1) Proton Pump Inhibitor Dashboard,

2) Anti-CD20 Antibody Dashboard,

3) Direct-Acting Antivirals-Hepatitis B Monitoring/Reactivation Dashboard, and

4) the GI-Azathioprine/6-Mercaptopurine Dashboard.

The Medication Safety (MedSafe) QUERI Program's national evaluation of the VA Office of Pharmacy Benefits Management’s (PBM) Medication Use Evaluation Tracker web application confirmed an interest in PBM/VA Center for Medication Safety (VA MedSAFE) for the development of national medication safety and appropriate medication use dashboards – to help identify and reduce potentially unsafe medication utilization.

In September 2017, in conjunction with PBM, Paul Heidenreich, MD, part of HSR&D’s Center for Innovation to Implementation (Ci2i) and principal investigator for the MedSafe QUERI Program, and HSR&D/QUERI investigator, Anju Sahay, PhD, invited subject matter experts, VISN Pharmacy Executives, and other key stakeholders to join VA PBM and VAMedSAFE leaders to form the VA PBM National Medication Safety Dashboard Committee. VAMedSAFE is led by Francesca Cunningham, PharmD, who, along with Dr. Paul Heidenreich and Dr.  Sahay serve on the VA PBM National Medication Safety Dashboard Committee. This Committee meets quarterly and prioritized the development of five national dashboards as population health management tools. These dashboards are being designed to identify at-risk Veterans across all VA sites with regular data updates and daily accessibility to VA clinicians.

DOACs and COVID-19: The coronavirus disease may expose patients to increased risk for thrombosis, with prevalence rates from early reports ranging from 3-35% (Schutgens, 2021). See COVID-19 Treatment guidelines for “Antithrombotic Therapy in Patients with COVID-19” (NIH, 2021)

The Direct Oral Anticoagulant (DOAC) Dashboard is a patient management tool originally developed as a facility/VISN initiative. It was evaluated as a candidate for national use based on the occurrence of adverse events and the risk of therapeutic failures related to DOAC therapy. VAMedSAFE validated and optimized the report with the developer, and, in conjunction with the MedSafe QUERI Program, the DOAC Dashboard became the first national medication safety dashboard. In July 2019 it was made available at all 146 VA sites. The potential risks associated with DOAC use are evaluated and set as patient flags on the dashboard.  Some of these flags include dosing issues, notable labs, medication interactions, and indications for use. 

Findings

In implementing the DOAC Dashboard, HSR&D/QUERI investigators determined that the implementation strategies used most often by pharmacists included patient mailings, provider education, electronic reminders, and emailing draft orders. Strategies used least often by pharmacists included calling patients, academic detailing, and patient-specific care plans.

Impacts

The Direct Oral Anticoagulants (DOAC) Dashboard is a population health management tool which has been implemented at 130 (89%) VA healthcare sites and it is in the process of being implemented at the remaining 16 (11%) VA sites. Altogether, 2,794 VA staff have been trained and/or currently use it. The DOAC Dashboard has served 277,826 Veterans.

Partner

VA’s Office of Pharmacy Benefits Management (PBM) Service.

Publications

Valencia D, Spoutz P, Stoppi J, Kibert JL 2nd, Allen A, Parra D, Hough A. Impact of a Direct Oral Anticoagulant Population Management Tool on Anticoagulation Therapy Monitoring in Clinical Practice. Ann Pharmacother. 2019 Aug;53(8):806-811. doi: 10.1177/1060028019835843. Epub 2019 Mar 10. PMID: 30854862

Rossier C, Spoutz P, Schaefer M, Allen A, Patterson ME. Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management. J Thromb Thrombolysis. 2021 Jul;52(1):200-208. doi: 10.1007/s11239-020-02341-y. Epub 2020 Nov 22. PMID: 33222115

Barnes G, Sippola E, Dorsch M, et al. Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol. Implement Science. September 2020:21;15(1):83.

Allen AL, Lucas J, Parra D, Spoutz P, Kibert JL 2nd, Ragheb B, Chia L, Sipe A. Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants. J Am Heart Assoc. 2021 Dec 21;10(24):e022758. doi: 10.1161/JAHA.121.022758. Epub 2021 Nov 19. PMID: 34796718.


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