Abstract 167: Impact of a Pharmacist-Led Outpatient Direct Oral Anticoagulation Service

Abstract

Background: Direct oral anticoagulants (DOACs) represent novel alternatives to vitamin K antagonists but present new challenges for appropriate prescribing and ongoing patient adherence. We assessed the impact of a pharmacist-led DOAC service on prescription appropriateness and patient adherence as compared to usual care. Methods: We performed a retrospective, observational, matched cohort analysis of patients prescribed a DOAC at a large academic medical center between September 20, 2013 and December 31, 2014. We compared a group of patients (n=129) who participated in a pharmacist-led DOAC service to a matched group (n=129) who received usual care using coarsened exact matching based on prescriber specialty, DOAC prescribed, indication for anticoagulation and age. Co-primary endpoints included the percentage of patients who had appropriate DOAC therapy (FDA-approved medication and dose based on indication and renal function) prescribed at baseline and at 3-6 month follow up after initiating the medication. Secondary endpoints included mean medication possession ratios (MPR) for patients who received at least 3 months of DOAC therapy and had available pharmacy records (n=171). We performed multivariable logistic regression modeling for appropriate prescription and multivariable linear regression modeling for MPR. Results: Patients in the two groups were well balanced across multiple demographic and comorbid factors. Patients in the pharmacist-led DOAC service were significantly more likely to have an appropriate combination of DOAC and dose prescribed for their indication at baseline as compared to usual care (92.2% vs. 77.5%; adjusted odds ratio [aOR] 3.02, p=0.006). This finding persisted at follow up (93.7% vs. 81.1%; aOR=2.92, p=0.016). There was no significant difference between groups in the number of patients determined to have an appropriate DOAC prescribed for an FDA-approved indication (independent of dose) in the pharmacist-led service (95.3%) vs usual care (93.0%) at baseline (aOR 0.93, p=0.901). Patients in the pharmacist-led service had a mean adjusted MPR of 91.8% compared to 79.3% with usual care (p=0.001) over a median follow up of 248 days. Conclusions: A pharmacist-led DOAC service increases appropriate dosing of DOACs at baseline and follow up as well as patient adherence to therapy. Associated costs and clinical event rates associated with pharmacist-lead DOAC management remain to be investigated.