Using population health-based strategies to optimize use of direct-acting oral anticoagulants in atrial fibrillation

Introduction Pharmacists deploy a variety of population-health strategies to identify needs related to pharmacotherapy. One area that deserves closer attention is medication management in atrial fibrillation (AF) since managing stroke prevention in older adults with AF requires delicately balancing the risk of thrombosis with the risk of bleeding. Objective(s) Evaluate direct-acting oral anticoagulant (DOAC) prescribing trends and explore strategies for mitigating gastrointestinal bleeding (GIB) risk in older adults prescribed a DOAC for stroke prevention in AF. Methods A quality improvement project was conducted and included Managed-Medicare patients from a single primary care organization prescribed a DOAC for AF. Pharmacists estimated risk of benefit and harm from the prescribed DOAC using established algorithms and patient characteristics documented in the medical record. They then forecasted the change in net clinical benefit if the prescribed DOAC was switched to a different DOAC. Results Overall, 200 patients met the inclusion criteria. Based on distribution of DOACs in the original study population, 52% of patients were in the definitive benefit group (benefit in reducing stroke risk outweigh risk of bleeding by 2-fold or greater), with 37% and 10.5% in the leaning benefit (reduction in stroke risk was up to 2-fold greater than bleeding risk) and leaning risk (bleeding risk was up to 2-fold greater than stroke risk reduction) groups, respectively. Calculation of risk should the prescribed DOAC be changed from rivaroxaban to apixaban was estimated to improve the net clinical benefit and reduce the risk of a patient falling in a negative clinical benefit group when compared to rivaroxaban and the original study population, respectively; 92% (relative risk [RR] 0.08 [0.026-0.277; P < 0.0001]) and 81% (RR 0.19 [0.067-0.545; P = 0.0002]). Conclusion Population health-based strategies centered on DOAC use in older adults can help identify prescribing trends and allow organizations to explore ways to mitigate risk of GIB. Preferential use of apixaban could reduce bleeding risk among older adults requiring anticoagulation for AF.