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

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.

Persistence and Surface Transport of Urea-Nitrogen: A Rainfall Simulation Study.

Studies of harmful algal blooms and associated urea concentrations in the Chesapeake Bay and in coastal areas around the globe strongly suggest that elevated urea concentrations are associated with harmful algal blooms. The observed increased frequency and toxicity of these blooms in recent decades has been correlated with increased agricultural use of N inputs and increased use of urea as a preferred form of commercial N. This rainfall simulation study sought to assess the potential for different N fertilizers and manures to contribute to urea in runoff from a Coastal Plain soil on the Eastern Shore of Maryland. Under worst-case conditions, ~1% of urea-N applied as commercial fertilizer and surface-applied poultry litter was lost in runoff in a simulated rainfall event, roughly equivalent to a 1-yr return period rain storm in the study area, 12 h after application. Cumulative urea-N losses, including four subsequent weekly rainfall events, approached 1.7% from urea-N fertilizer containing a urease inhibitor. Urea-N loss from incorporated poultry litter was negligible, and losses from dairy manure were intermediate. These losses are likely confined to hydrological contributing areas that extend several meters from a drainage ditch or stream for storms with frequent recurrence intervals. Cumulative dissolved N losses in runoff (urea-N + ammonium-N + nitrate-N) as a proportion of total applied plant-available N were <5%, suggesting that most of the applied N was lost by other pathways or was immobilized in soil. Results also highlight the potential for simple management options, such as shallow incorporation or timing, to greatly reduce urea runoff losses.

Using flue gas desulfurization gypsum to remove dissolved phosphorus from agricultural drainage waters.

High levels of accumulated phosphorus (P) in soils of the Delmarva Peninsula are a major source of dissolved P entering drainage ditches that empty into the Chesapeake Bay. The objective of this study was to design, construct, and monitor a within-ditch filter to remove dissolved P, thereby protecting receiving waters against P losses from upstream areas. In April 2007, 110 Mg of flue gas desulfurization (FGD) gypsum, a low-cost coal combustion product, was used as the reactive ingredient in a ditch filter. The ditch filter was monitored from 2007 to 2010, during which time 29 storm-induced flow events were characterized. For storm-induced flow, the event mean concentration efficiency for total dissolved P (TDP) removal for water passing through the gypsum bed was 73 ± 27% confidence interval (α = 0.05). The removal efficiency for storm-induced flow by the summation of load method was 65 ± 27% confidence interval (α = 0.05). Although chemically effective, the maximum observed hydraulic conductivity of FGD gypsum was 4 L s(-1), but it decreased over time to <1 L s(-1). When bypass flow and base flow were taken into consideration, the ditch filter removed approximately 22% of the TDP load over the 3.6-yr monitoring period. Due to maintenance and clean-out requirements, we conclude that ditch filtration using FGD gypsum is not practical at a farm scale. However, we propose an alternate design consisting of FGD gypsum-filled trenches parallel to the ditch to intercept and treat groundwater before it enters the ditch.

Phosphorus runoff losses from subsurface-applied poultry litter on coastal plain soils.

The application of poultry litter to soils is a water quality concern on the Delmarva Peninsula, as runoff contributes P to the eutrophic Chesapeake Bay. This study compared a new subsurface applicator for poultry litter with conventional surface application and tillage incorporation of litter on a Coastal Plain soil under no-till management. Monolith lysimeters (61 cm by 61 cm by 61 cm) were collected immediately after litter application and subjected to rainfall simulation (61 mm h(-1) 1 h) 15 and 42 d later. In the first rainfall event, subsurface application of litter significantly lowered total P losses in runoff (1.90 kg ha(-1)) compared with surface application (4.78 kg ha(-1)). Losses of P with subsurface application were not significantly different from disked litter or an unamended control. By the second event, total P losses did not differ significantly between surface and subsurface litter treatments but were at least twofold greater than losses from the disked and control treatments. A rising water table in the second event likely mobilized dissolved forms of P in subsurface-applied litter to the soil surface, enriching runoff water with P. Across both events, subsurface application of litter did not significantly decrease cumulative losses of P relative to surface-applied litter, whereas disking the litter into the soil did. Results confirm the short-term reduction of runoff P losses with subsurface litter application observed elsewhere but highlight the modifying effect of soil hydrology on this technology's ability to minimize P loss in runoff.

Occurrence of arsenic and phosphorus in ditch flow from litter-amended soils and barn areas.

Little is known about the fate of arsenic (As) in land-applied litter from chickens that have been fed roxarsone, an organic feed additive containing As. This study seeks to elucidate the transfer of As in runoff from ditch-drained soils of the poultry-producing region of the Delmarva Peninsula by tracking As and phosphorus (P) export from seven drainage ditches over two water-years (1 July 2005 to 30 June 2007). Annual losses of As from ditches ranged from 0.004 to 0.071 kg ha(-1) while P losses ranged from 0.33 to 18.56 kg ha(-1), with the largest loads associated with a litter storage shed that served as a point source. Event-based As and P losses in ditch flow fluctuated by a factor of 162 and 1882, respectively. The two elements were correlated in flow from the ditch draining a litter storage shed (r = 0.99), and in sediment extracts in soils near the litter shed (r = 0.73), pointing to similar behavior under point source conditions. Indeed, As and P exhibited similar behavior within storms for all ditches, characterized by relatively high initial concentrations subject to rapid concentration declines before peak flow, consistent with dilution of a finite source. However, As and P concentrations varied significantly between ditches and showed considerable temporal variability within ditches, with no clear seasonal trends or associations with current management strategies. The results suggest that similar management strategies might be effective for As and P point sources, but that field management practices geared toward controlling nonpoint source P losses may not readily transfer to the control of As losses.

Evaluating the success of phosphorus management from field to watershed.

Studies have demonstrated some P loss reduction following implementation of remedial strategies at field scales. However, there has been little coordinated evaluation of best management practices (BMPs) on a watershed scale to show where, when, and which work most effectively. Thus, it is still difficult to answer with a degree of certainty, critical questions such as, how long before we see a response and where would we expect to observe the greatest or least response? In cases where field and watershed scales are monitored, it is not uncommon for trends in P loss to be disconnected. We review case studies demonstrating that potential causes of the disconnect varies, from competing sources of P at watershed scales that are not reflected in field monitoring to an abundance of sinks at watershed scales that buffer field sources. To be successful, P-based mitigation strategies need to occur iteratively, involve stakeholder driven programs, and address the inherent complexity of all P sources within watersheds.

Vertical distribution of phosphorus in agricultural drainage ditch soils.

Pedological processes such as gleization and organic matter accumulation may affect the vertical distribution of P within agricultural drainage ditch soils. The objective of this study was to assess the vertical distribution of P as a function of horizonation in ditch soils at the University of Maryland Eastern Shore Research Farm in Princess Anne, Maryland. Twenty-one profiles were sampled from 10 agricultural ditches ranging in length from 225 to 550 m. Horizon samples were analyzed for total P; water-extractable P; Mehlich-3 P; acid ammonium oxalate-extractable P, Fe, and Al (P ox, Fe ox, Al ox); pH; and organic C (n = 126). Total P ranged from 27 to 4882 mg kg(-1), P ox from 4 to 4631 mg kg(-1), Mehlich-3 P from 2 to 401 mg kg(-1), and water-extractable P from 0 to 17 mg kg(-1). Soil-forming processes that result in differences between horizons had a strong relationship with various P fractions and P sorption capacity. Fibric organic horizons at the ditch soil surface had the greatest mean P ox, Fe ox, and Al ox concentrations of any horizon class. Gleyed A horizons had a mean Fe ox concentrations 2.6 times lower than dark A horizons and were significantly lower in total P and P ox. Variation in P due to organic matter accumulation and gleization provide critical insight into short- and long-term dynamics of P in ditch soils and should be accounted for when applying ditch management practices.

Spatial variation of soil phosphorus within a drainage ditch network.

Agricultural drainage ditches serve as P transport pathways from fields to surface waters. Little is known about the spatial variation of P at the soil-water interface within ditch networks. We quantified the spatial variation of surficial (0-5 cm) soil P within vegetated agricultural ditches on a farm in Princess Anne, MD with an approximately 30-yr history of poultry litter application. Ditch soils from 10 ditches were sampled at 10-m intervals and analyzed for acid ammonium oxalate-extractable P, Fe, Al (P(ox), Fe(ox), Al(ox)), and pH. These variables were spatially autocorrelated. Oxalate-P (min = 135 mg kg(-1), max = 6919 mg kg(-1), mean = 700 mg kg(-1)) exhibited a high standard deviation across the study area (overall 580 mg kg(-1)) and within individual ditches (maximum 1383 mg kg(-1)). Several ditches contained distinct areas of high P(ox), which were associated with either point- or nonpoint-P sources. Phosphorus was correlated with Al(ox) or Fe(ox) within specific ditches. Across all ditches, Al(ox) (r = 0.80; p < 0.001) was better correlated with P(ox) than was Fe(ox) (r = 0.44; p < 0.001). The high level of spatial variation of soil P observed in this ditch network suggests that spatially distributed sampling may be necessary to target best management practices and to model P transport and fate in ditch networks.