Coagulation

Suboptimal use of anticoagulants and DAPT shows need for medication reviews: report


Underuse of oral anticoagulants following admission for atrial fibrillation (AF) and dual antiplatelet therapy following acute myocardial infarction (AMI) is common, a Victorian study has shown.

Only 30.4% of patients with a primary or secondary diagnosis of AF were using oral anticoagulants within 30 days of discharge, a National Data Linkage Demonstration Project from the Victorian Agency for Health Information found.

The highest rates of dispensing an oral anticoagulant within 30 days were observed for people with a CHA2DS2-VASc score ≥ 2 (31.1%), a primary diagnosis of AF (39.0%), a prior dispensing of an oral anticoagulant (54.2%), direct current cardioversion on most recent admission (54.2%); and a prior hospitalisation for stroke (43.3%).

The findings were based on data from 33,806 patients admitted across facilities of all sizes in metropolitan and regional areas of the state.

There was also considerable variability – from 22% to 40% – in the use of oral anticoagulants based on the hospital of discharge indicating the potential for improvement even in the best performing hospitals.

“Despite evidence-based recommendations to prescribe oral anticoagulants post-hospital discharge for most patients with AF, two-thirds of patients were not dispensed an oral anticoagulant within 30 days of discharge, and more than half were not dispensed an oral anticoagulant in the first year,” the project report said.

“Even a modest increase (i.e 10%) on the rate of oral anticoagulant dispensing reported by this study could prevent a significant number of strokes and ultimately deaths.”

Data from 10,639 patients with acute MI showed only 53.9% were prescribed an ADP receptor antagonist such as clopidogrel or dual antiplatelet therapy (DAPT) such as clopidogrel plus aspirin.

The variability between hospitals ranged from 22 to 74%.

“Due to contraindications and the risk of major bleeding from DAPT, it is not realistic to expect hospitals to have all patients with discharge diagnosis of AMI to be prescribed DAPT.”

“However, the wealth of data regarding clinical effectiveness of DAPT in patients with acute coronary syndrome (ACS) suggests increased prescribing would have a net benefit by decreasing the rates of recurrent AMI and stroke.”

Dr Lance Emerson, CEO of the Victorian Agency for Health Information, told the limbic that variation in care was common across health service delivery.

“There is variation, and it’s great that we now have empirical data to show this. After all – we can’t raise the bar without first knowing where the bar is.”

He said the report acknowledged that further work was required to determine the factors influencing dispensing at patient discharge and help health services improve the care they were providing.

There was evidence that pharmacist review of medications can assist, Dr Emerson said.

“Hospital pharmacists, in particular, have an important role in reviewing patients’ scripts prior to discharge, and processes could be implemented to use them as an added layer of medication review prior to hospital discharge. A post-hospital medication review by a pharmacist in a domiciliary setting could also assist.”

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