Abstract 15444: Anticoagulation Treatment of Venous Thromboembolism Across the Weight Spectrum: Insights From the Veterans Health Administration

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Alexander C Perino ◽  
Jun Fan ◽  
Mitra Kothari ◽  
ATIF MOHAMMAD ◽  
Patrick Hlavacek ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Treatment Strategies ◽  
Veterans Health ◽  
Health Administration ◽  
Mechanical Valves ◽  
Consensus Statements ◽  
Body Weights ◽  
Va Health Care System

Introduction: In seminal trials of venous thromboembolism (VTE) treatment with direct oral anticoagulants (DOAC), few patients were enrolled at low and high body weights to estimate treatment effects in these subgroups. Consensus statements have recommended against use of DOACs in VTE for patients ≥120 kg. We sought to describe real-world use of DOACs and other anticoagulants for VTE across the weight spectrum. Methods: We performed a retrospective cohort study of patients with first-time VTE that were treated with anticoagulants in the VA health care system from 2008 to 2018. We excluded patients with 1) additional indications for anticoagulation (atrial fibrillation and mechanical valves) and 2) no documented weight in the 90 days prior to 90 days after index VTE. We stratified patients by weight (<60, 60 to 119, ≥120 kg) and determined 1) index anticoagulation prescription in the 30 days after index VTE (DOAC, warfarin, and low molecular weight heparin or fondaparinux [LMWH/F] only) and 2) variables associated with DOAC prescription, as compared to warfarin, in those ≥120 kg. Results: After excluding 3,676 patients with missing weight, there were 111,774 patients with VTE (64±13 years, 6% female). The most common therapy was warfarin (66%), followed by DOAC (21%), and LMWH/F only (13%). Median weight was 92 kg (interquartile range: 28), with 13,753 patients (12%) with weight ≥120 kg. Across weight categories, proportion of patients receiving DOAC was similar. In patients ≥120 kg, after multivariate adjustment, multiple comorbidities were associated with warfarin prescription while chronic kidney disease was associated with DOAC prescription ( Table ). Conclusion: Weight ≥120 kg is common for VTE patients, with DOAC frequently prescribed despite consensus statements recommending DOAC avoidance. For patients ≥120 kg, comorbidities influence VTE treatment selection, and determination of optimal treatment strategies across the spectrum of comorbidities is needed.

scholarly journals Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Geoffrey D. Barnes ◽  
Emily Sippola ◽  
Michael Dorsch ◽  
Joshua Errickson ◽  
Michael Lanham ◽  
...  
Keyword(s):  
Technology Acceptance ◽  
Population Health ◽  
Health Systems ◽  
Adverse Drug Events ◽  
Oral Anticoagulants ◽  
Qualitative Interviews ◽  
Direct Oral Anticoagulants ◽  
Veterans Health ◽  
Health Administration ◽  
Implementation Effort

Abstract Background Use of direct oral anticoagulants (DOAC) is rapidly growing for treatment of atrial fibrillation and venous thromboembolism. However, incorrect dosing of these medications is common and puts patients at risk of adverse drug events. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR). As such tools become more common, exploring ways to understand which aspects are effective in specific settings and how to effectively adapt and implement in existing anticoagulation clinics across different health systems is vital. Methods This three-phase project will evaluate a current nation-wide implementation effort of the DOAC Dashboard in the Veterans Health Administration (VHA) using both quantitative and qualitative methods. Informed by this evaluation, the DOAC Dashboard will be implemented in four new health systems using an implementation strategy derived from the VHA experience and interviews with providers in those new health systems. Quantitative evaluation of the VHA and non-VHA implementation will follow the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Qualitative interviews with stakeholders will be analyzed using the Consolidated Framework for Implementation Research and Technology Acceptance Models to identify key determinants of implementation success. Discussion This study will (1) evaluate the implementation of an EHR-based population health tool for medication management within a large, nation-wide, highly integrated health system; (2) guide the adoption in a set of four different health systems; and (3) evaluation that multi-center implementation effort. These findings will help to inform future EHR-based implementation efforts in a wide variety of health care settings.

scholarly journals Direct Oral Anticoagulant Adherence of Patients With Atrial Fibrillation Transitioned from Warfarin

2021 ◽  
Author(s):  
Krishna N. Pundi ◽  
Alexander C. Perino ◽  
Jun Fan ◽  
Susan Schmitt ◽  
Mitra Kothari ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
International Normalized Ratio ◽  
Veterans Health ◽  
Health Administration ◽  
Ratio Data ◽  
Proportion Of Days Covered ◽  
Increase Risk ◽  
Using Data

Background Reduced time in international normalized ratio therapeutic range (TTR) limits warfarin safety and effectiveness. In patients switched from warfarin to direct oral anticoagulants (DOACs), patient factors associated with low TTR could also increase risk of DOAC nonadherence. We investigated the relationship between warfarin TTR and DOAC adherence in warfarin‐treated patients with atrial fibrillation switched to DOAC. Methods and Results Using data from the Veterans Health Administration, we identified patients with atrial fibrillation switched from warfarin to DOAC (switchers) or treated with warfarin alone (non‐switchers). Logistic regression was used to evaluate association between warfarin TTR and DOAC adherence. We analyzed 128 605 patients (age, 71±9; 1.6% women; CHA 2 DS 2 ‐VASc 3.5±1.6); 32 377 switchers and 96 228 non‐switchers. In 8016 switchers with international normalized ratio data to calculate 180‐day TTR before switch, TTR was low (median 0.45; IQR, 0.26–0.64). Patients with TTR <0.5 were more likely to be switched to DOAC (odds ratio [OR],1.68 [95% CI,1.62–1.74], P <0.0001), as were those with TTR <0.6 or TTR <0.7. Proportion of days covered ≥0.8 was achieved by 76% of switchers at 365 days. In low‐TTR individuals, proportion of days covered ≥0.8 was achieved by 70%, 72%, and 73% of switchers with TTR <0.5, 0.6, and 0.7, respectively. After multivariable adjustment, TTR <0.5 decreased odds of achieving 365‐day proportion of days covered ≥0.8 (OR, 0.49; 0.43–0.57, P <0.0001), with similar relationships for TTR <0.6 and TTR <0.7. In non‐switchers with TTR <0.5, long‐term TTR remained low. Conclusions In patients with atrial fibrillation switched from warfarin to DOAC, most achieved adequate DOAC adherence despite low pre‐switch TTRs. However, TTR trajectories remained low in non‐switchers. Patients with low warfarin TTR more consistently achieved treatment targets after switching to DOACs, although adherence‐oriented interventions may be beneficial.

scholarly journals Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants

2021 ◽  
Author(s):  
Arthur L. Allen ◽  
Jessica Lucas ◽  
David Parra ◽  
Patrick Spoutz ◽  
Jeffery L. Kibert ◽  
...  
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Inappropriate Prescribing ◽  
Population Based ◽  
Management Tool ◽  
Management Approach ◽  
Veterans Health ◽  
Health Administration ◽  
The Impact

Abstract Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60‐year standard of care from one‐to‐one provider‐to‐patient anticoagulation monitoring to a population‐based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.

Abstract 231: Racial and Ethnic Disparities in Anticoagulant Choice for Atrial Fibrillation in the Veterans Health Administration: Results From the REACH AF Study

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Utibe R Essien ◽  
Nadejda Kim ◽  
Leslie Hausmann ◽  
Maria Mor ◽  
Chester Good ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Anticoagulant Therapy ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Ethnic Disparities ◽  
Veterans Health ◽  
Health Administration ◽  
Race Ethnicity ◽  
Racial Ethnic

Background: Atrial fibrillation (AF) affects nearly 1 million patients in VA, with morbidity and mortality disproportionately affecting racial/ethnic minorities. Anticoagulation reduces stroke risk in AF, yet warfarin and direct oral anticoagulants (DOACs) are underused in minorities. We compared anticoagulant initiation by race/ethnicity for patients with AF in VA—which facilitates access to medications through a uniform drug formulary. Methods: Using the VA Corporate Data Warehouse, we identified patients from 1/1/2014 - 12/31/2018 with an AF diagnosis and a confirmatory diagnosis ≦180 days of their index AF diagnosis. We excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis, as well as those with valvular heart disease, who died within 180 days of AF diagnosis, or had missing or “other” race/ethnicity. We categorized our independent variable as non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic. Our primary outcome was receipt of any anticoagulant ≦180 days of AF diagnosis as well as the type of anticoagulant (warfarin, DOAC) initiated. We used logistic regression to compare outcomes by race/ethnicity, adjusting for year of diagnosis, stroke risk with CHADS2VA2Sc score, renal disease, region and rurality. Results: We identified 148,062 patients with incident AF: 8.6% were NHB, 3.4% Hispanic. Overall, NHBs (57.7%) and Hispanics (58.4%) were less likely than NHWs (61.4%) to initiate any anticoagulant therapy (p <0.01), driven by lower DOAC initiation for minorities (36.8% NHBs, 36.5% Hispanics, 43.0% NHWs; p <0.01). Compared to NHWs, the adjusted odds ratios (AORs) for receiving any anticoagulant or DOACs were significantly lower for NHBs and Hispanics (Table); in contrast, AORs for receiving warfarin were significantly higher among minorities. As DOAC initiation increased from 16.8% (2014) to 60.3% (2018), racial disparities in initiation increased from 1.7 to 9.1% for NHBs vs. NHWs and from 0.9 to 9.4% for Hispanics vs. NHWs. Conclusions: In a national cohort of AF in VA, we identified significant racial/ethnic disparities in anticoagulant initiation, driven by growing disparities in DOAC initiation. Understanding these differences is essential to ensuring equitable AF care in the largest U.S. integrated health care system.

scholarly journals Safety and efficacy of direct oral anticoagulants (DOACs) vs low molecular weight heparin (LMWH) in malignancy induced venous thromboembolism-a systematic review and meta analysis

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
A Abdul Razzack ◽  
N Hussain ◽  
S Adeel Hassan ◽  
S Mandava ◽  
F Yasmin ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Venous Thromboembolism ◽  
Major Bleeding ◽  
Low Molecular Weight Heparin ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Efficacy And Safety ◽  
Dichotomous Data ◽  
Significant Difference

Abstract Funding Acknowledgements Type of funding sources: None. Background- Low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) have been proven to be more effective in the management of venous thromboembolism (MVTE). The efficacy and safety of LMWH or DOACs in treatment of recurrent or malignancy induced VTE is not studied in literature. Objective To compare the efficacy and safety of LMWH and  DOACs in the management of malignancy induced  VTE Methods- Electronic databases ( PubMed, Embase, Scopus, Cochrane) were searched from inception to November  28th, 2020. Dichotomous data was extracted for prevention of VTE and risk of major bleeding in patients taking either LMWH or DOACs. Unadjusted odds ratios (OR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance to be considered if the confidence interval excludes 1 and p &lt; 0.05.  Results- Three studies with 2607 patients (DOACs n = 1301 ; LMWH n = 1306) were included in analysis. All the study population had active cancer of any kind diagnosed within the past 6 months. Average follow-up period for each trial was 6 months. Patients receiving DOACs have a lower odds of recurrence of MVTE as compared to LMWH( OR 1.56; 95% CI 1.17-2.09; P = 0.003, I2 = 0). There was no significant difference in major bleeding among patients receiving LMWH or DOACs  (OR-0.71, 95%CI 0.46-1.10, P = 0.13, I2 = 22%) (Figure 1). We had no publication bias in our results (Egger’s regression p &gt; 0.05). Conclusion- DOACs are superior to LMWH in prevention of MVTE and have similar major bleeding risk as that of LMWH. Abstract Figure. A)VTE Recurrence B)Major Bleeding events

Sign in / Sign up

Export Citation Format

Share Document