Comparison of decentralized versus centralized pharmacist management of patients with atrial fibrillation treated with direct oral anticoagulants (DOACs)

Introduction: Patients prescribed dabigatran from the Ralph H. Johnson VA Medical Center (RHJ VAMC) were originally managed by 12 primary care pharmacists by telephone visits to closely monitor adherence, safety and efficacy, but then were transitioned to a centralized clinic with three clinical pharmacy specialists. Objectives: The purpose of this study was to investigate how this centralization of DOAC management affected patient adherence, safety outcomes and pharmacotherapy visits. Study Design: This single-center, retrospective medication use evaluation included two study periods between November 1, 2011 and October 31, 2013. Eligible patients received anticoagulation therapy with dabigatran from RHJ VAMC’s outpatient pharmacy. Outcomes were compared between two time periods around centralization of DOAC management. Methods: The primary outcome was adherence to the DOAC, as measured by medication possession ratio (MPR). Secondary outcomes included safety and change in amount of visits by primary care pharmacists. The study was approved by expedited IRB and VA R&D committees. Results: Sixty-five unique patients prescribed dabigatran were included in the analysis. The primary outcome of MPR was similar between the two groups: 1.01 (range 0.59-1.41) and 0.96 (0.33-1.36) for pre-centralization and post-centralization study periods, respectively (p=0.91). The secondary analysis showed no statistically significant difference between the incidences of bleeding events. There were no thromboembolisms in the pre-centralization group and one in the post-centralization study group. The tertiary endpoint revealed a 108% increase in primary care pharmacist visits from pre- to post-centralization. Conclusions: This study revealed a high rate of dabigatran adherence was retained through centralization of DOAC management by pharmacists. This centralization also resulted in a 108% increase in primary care pharmacist visits without addition of more staff. Overall, this study supports the safe and effective use of centralized pharmacist services for DOAC management in an outpatient setting to retain high rates of patient adherence.