Central Virginia VA Health Care System, Richmond, VA, USA.
Department of Veterans Affairs VISN #20, VA Northwest Health Network, Vancouver, WA, USA.
J Thromb Thrombolysis. 2021 Jul;52(1):200-208. doi: 10.1007/s11239-020-02341-y. Epub 2020 Nov 22.
Inappropriate direct acting oral anti-coagulants (DOAC) prescribing increases the risk of adverse events. Population health management tools (PMTs) could help reduce adverse events through the early, efficient identification of questionable prescribing practices, but the impact of such a tool remains unknown. We evaluated the effect of PMT use on questionable DOAC dosing rates within 40 VHA medical centers and whether this effect differed by DOAC indication or agent. Medical centers were divided into PMT user or standard of care (SOC) groups based upon high or low tool access in the prior year. Questionable DOAC dosing rate was defined as the proportion of patients prescribed DOACs who were also flagged by the tool. Chi-square tests were used to determine if PMT user versus SOC groups differed with high (above 15.3%) versus low (below 15.3%) questionable dosing rates. T-tests were used to determine if mean questionable dosing rates significantly differed between the PMT user and SOC groups. DOAC PMT users were classified less frequently as being 'High" questionable dosage rate compared to SOCs (25% PMT vs. 75% SOC, respectively, p = 0.002). DOAC PMT utilization within the overall cohort was associated with a 4.3% absolute reduction in questionable DOAC dosing rates (13.2% PMT vs 17.5% SOC; p = 0.01). Tool use within the atrial fibrillation (AF) subgroup was associated with a 5.1% absolute reduction in questionable dosing rates (10.4% SOC vs. 5.3% PMT, p < 0.001). Tool use was also associated with lower questionable dosing rates in the apixaban (p < 0.001), dabigatran (p = 0.03) and AF plus venous thromboembolism (p < 0.001) subgroups. In our study, PMT use was associated with reduced questionable DOAC dosing, a difference most pronounced within AF patients. A population health approach has the potential to reduce adverse events among patients prescribed DOACs.
不适当的直接口服抗凝剂（DOAC）处方会增加不良事件的风险。人群健康管理工具（PMT）可以通过早期、高效地识别有问题的处方实践来帮助减少不良事件，但这种工具的效果尚不清楚。我们评估了 PMT 使用对 40 家 VHA 医疗中心内有问题的 DOAC 剂量率的影响，以及这种影响是否因 DOAC 适应证或药物而不同。根据前一年高或低工具使用率，将医疗中心分为 PMT 用户或标准护理（SOC）组。有问题的 DOAC 剂量率定义为被工具标记的同时处方 DOAC 的患者比例。卡方检验用于确定 PMT 用户与 SOC 组在高（高于 15.3%）与低（低于 15.3%）有问题的剂量率方面是否存在差异。t 检验用于确定 PMT 用户与 SOC 组之间的平均有问题的剂量率是否存在显著差异。与 SOC 相比，DOAC PMT 用户被归类为“高”有问题的剂量率的频率较低（分别为 25%PMT 与 75%SOC，p=0.002）。在整个队列中，DOAC PMT 的使用与有问题的 DOAC 剂量率绝对降低 4.3%相关（PMT 为 13.2%，SOC 为 17.5%；p=0.01）。AF 亚组中工具的使用与有问题的剂量率绝对降低 5.1%相关（SOC 为 10.4%，PMT 为 5.3%，p<0.001）。工具的使用还与阿哌沙班（p<0.001）、达比加群（p=0.03）和 AF 加静脉血栓栓塞（p<0.001）亚组中较低的有问题的剂量率相关。在我们的研究中，PMT 的使用与降低有问题的 DOAC 剂量相关，在 AF 患者中这种差异最为明显。人群健康方法有可能降低处方 DOAC 的患者的不良事件。
