Venous thromboembolism management in people with cystic fibrosis.

BACKGROUND: Rates of venous thromboembolism (VTE) are increasing in people with cystic fibrosis (PwCF). Providers treating VTE in PwCF have reported low confidence concerning anticoagulant drug selection, dose, duration, and drug-drug interactions. As there are currently no published reports regarding management of VTE in PwCF, our objective was to describe the management of VTE in PwCF. METHODS: PwCF and VTE at the University of Utah Health were identified through electronic medical record searches. Patients were categorized into one of three treatment groups: warfarin, direct oral anticoagulant (DOAC), and low molecular weight heparin (LMWH). The primary outcome was episodes of major bleeding. Secondary outcomes included clinically relevant nonmajor (CRNM) bleeding. RESULTS: Nine PwCF with a total of 12 unique VTE episodes were included in the study, with all but one episode associated with a peripherally inserted central catheter (PICC). Of the 12 VTE cases, 25% were treated with warfarin, 50% with a DOAC, and 25% with LMWH. There were no episodes of major bleeding and only one episode of CRNM bleeding (Hemoptysis) in the LMWH group. All anticoagulant doses and durations generally followed guidelines for persons without CF. DOACs were the most common VTE treatment, at doses and duration consistent with guidelines for persons without CF, with no major or CRNM bleeding. CONCLUSION: VTE treatment in PwCF is generally consistent with guidelines for persons without CF with low rates of bleeding. DOACs are a potential option for treatment of VTE in PwCF, but more research is needed.

Over the Hills and Through the Hollers: How One Program is Assisting Residents of Appalachian with Opioid Use Recovery.

Introduction: The consequences of increasing opioid misuse in the U.S. over the last two decades have been severe, contributing to hundreds of thousands of lives lost and heavy tolls on individuals, families, and society. The Appalachian Region has been hit particularly hard, with its predominantly rural landscape seeing disproportionate increases in opioid misuse and overdoses. These cases have been difficult to address due to poor treatment access and capacity constraints in many areas of Appalachia. Purpose: The current study focuses on evaluating The Kentucky Access to Recovery Program (KATR), which provides services to individuals recovering from opioid addiction residing in several counties in Eastern Kentucky. Its purpose is to understand the impact of KATR on service recipients' access to recovery services and supports. Methods: Semi-structured interviews were conducted with 12 service recipients, three service providers, and four vendors of support services related to housing, transportation, medical/dental care, employment, and childcare. Qualitative data were analyzed using thematic analysis. Results: Themes related to individual-level impacts were identified and discussed, including behavioral changes related to recovery, physical and mental health improvements, relationship repair, regaining custody of children, provision of needed supports, and ability to gain employment and improve finances. Study findings showed that KATR had meaningful impacts on the lives of service recipients by helping meet needs and reducing barriers to their ongoing recovery. Implications: Through its use of vouchers for support services and basic-needs provision, KATR demonstrates a potentially effective strategy for increasing access to health-related social services for persons in recovery in predominantly rural areas.

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences.

INTRODUCTION: The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma. METHODS: The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation. RESULTS: Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation. CONCLUSIONS: NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.

Trends in antiplatelet strategies 12-months following coronary stent placement in anticoagulated patients.

BACKGROUND: Antithrombotic guidelines for patients undergoing percutaneous coronary interventions (PCIs) and also requiring anticoagulant medications are evolving. This study describes changes to antithrombotic therapy and associated outcomes 12-months following PCI in patients requiring ongoing anticoagulation therapy. METHODS: Records of patients identified from queries of electronic medical records were manually reviewed to verify changes to antithrombotic therapy from discharge to 12-months and at 12-months following PCI, and episodes of major bleeding, clinically relevant non-major bleeding (CRNMB), major adverse cardiovascular or neurological events (MACNE), and all-cause mortality outcomes during an additional 6-months follow-up. RESULTS: Patients (n = 120) receiving anticoagulation therapy at 12-months post PCI were classified into the following groups according to antiplatelet therapy status: no antiplatelet therapy (n = 16), single antiplatelet therapy (SAPT) (n = 85), and dual antiplatelet therapy (DAPT) (n = 19). Between 12- and 18-months following PCI there were 2 major bleeds, 7 CRNMB, 6 MACNE, 2 venous thromboembolisms, and 5 deaths. All but one bleeding episode occurred in the SAPT group. The odds of remaining on DAPT at 12-months were higher in patients who had PCI for acute coronary syndrome (odds ratio [OR] 2.91, 95% confidence interval [CI] 0.96, 8.77), and in those experiencing MACNE in the 12-months following PCI (OR 1.95, 95% CI 0.67, 5.66), but these associations were not statistically significant. CONCLUSION: Most anticoagulated patients were continued on antiplatelet therapy 12-months post PCI. Bleeding was numerically more common in anticoagulated patients continuing SAPT therapy beyond 12 months. There was significant variability in antithrombotic prescribing patterns 12-months post PCI suggesting a potential opportunity for standardizing care in this patient population.

Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation.

Introduction: Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design: Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results: User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations: These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions: Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights: First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.

Impacts of the COVID-19 Pandemic on a Rural Opioid Support Services Program.

During 2020, Kentucky saw the third highest increase in overdose deaths in the U.S. Employment issues, inadequate housing, transportation problems, and childcare needs present barriers to accessing treatment in rural areas. These barriers and others (e.g., technology) arose during the pandemic negatively affecting individuals in recovery and service providers as they adjusted services to provide primarily telehealth and remote services. This study examines the impact of COVID-19 in its early stages on an opioid use disorder (OUD) support services program in a nonprofit located in rural eastern Kentucky, part of the central Appalachia region. A qualitative design was applied, employing semi-structured interviews in early fall 2020. Participants were associated with one OUD support services program, including service recipients, program coordinators, and business vendors. Guided by the Social Determinants of Health framework, two-cycle coding-descriptive coding and pattern coding-was utilized. Codes were sorted into three patterns: changes to daily life; financial impacts; and service access and provision. Overall, early stages of COVID-19 brought increased stress for individuals in recovery, as they were taking on more responsibility and navigating a changing environment. Coordinators were under pressure to provide services in a safe, timely manner. Vendors vocalized their struggles and successes related to finances. These findings can help organizations make realistic adjustments and policymakers set reasonable expectations and consider additional financial support.

Randomized evaluation of decision support interventions for atrial fibrillation: Rationale and design of the RED-AF study.

BACKGROUND: Shared decision making (SDM) improves the likelihood that patients will receive care in a manner consistent with their priorities. To facilitate SDM, decision aids (DA) are commonly used, both to prepare a patient before their clinician visit, as well as to facilitate discussion during the visit. However, the relative efficacy of patient-focused or encounter-based DAs on SDM and patient outcomes remains largely unknown. We aim to directly estimate the comparative effectiveness of two DA's on SDM observed in encounters to discuss stroke prevention strategies in patients with atrial fibrillation (AF). METHODS: The study aims to recruit 1200 adult patients with non-valvular AF who qualify for anticoagulation therapy, and their clinicians who manage stroke prevention strategies, in a 2x2 cluster randomized multi-center trial at six sites. Two DA's were developed as interactive, online, non-linear tools: a patient decision aid (PDA) to be used by patients before the encounter, and an encounter decision aid (EDA) to be used by clinicians with their patients during the encounter. Patients will be randomized to PDA or usual care; clinicians will be randomized to EDA or usual care. RESULTS: Primary outcomes are quality of SDM, patient decision making, and patient knowledge. Secondary outcomes include anticoagulation choice, adherence, and clinical events. CONCLUSION: This trial is the first randomized, head-to-head comparison of the effects of an EDA versus a PDA on SDM. Our results will help to inform future SDM interventions to improve patients' AF outcomes and experiences with stroke prevention strategies.

Exploring clinician perspectives on patients with atrial fibrillation who are not prescribed anticoagulation therapy.

Objective: To explore themes underlying why anticoagulants are under-prescribed for stroke prevention in atrial fibrillation (AF) patients from the clinician's perspective and characteristics of those patients. Methods: Clinicians at the University of Utah Health system were recruited for semi-structured 15-minute interviews. An interview guide focused on anticoagulant prescribing practices for patients with AF. Interviews were transcribed verbatim. Two reviewers independently coded passages corresponding with key themes. Results: Eleven practitioners were interviewed from cardiology, internal medicine, and family practice. Five themes were found: the role of compliance in anticoagulation decision making, the role of pharmacists in supporting clinicians, the use of shared decision making and risk communication, risk of bleeding as the main barrier to taking anticoagulants, and the variety of reasons patients have for not starting or discontinuing anticoagulants. Conclusion: Fear of bleeding was the foremost reason underlying anticoagulant underutilization in patients with AF followed by compliance, and patient worries. Communication between patients and clinicians as well as interdisciplinary teamwork are key to understanding and improving anticoagulant prescribing in AF. Innovation: Our study was the first to assess the role pharmacists play in prescribing clinician's decisions surrounding anticoagulant use in AF. Pharmacists could play an important collaborative role in SDM.

Outcomes of isolated distal thrombosis managed with serial compression ultrasonography.

BACKGROUND: Isolated distal deep vein thrombosis (IDDVT) is a common subtype of deep vein thrombosis (DVT). Consensus guidelines provide conflicting recommendations for IDDVT management; some recommend anticoagulant treatment, while others suggest serial compression ultrasonography (CUS) monitoring for patients not at "high risk" of proximal extension. The purpose of this study was to describe outcomes of serial CUS-monitored IDDVT and identify risk factors for proximal thrombus extension or anticoagulant treatment initiation. METHODS: A retrospective descriptive study was conducted using electronic data from University of Utah Health. Adult subjects with objectively confirmed, serial CUS-monitored IDDVT were included. Subjects were followed for 30 days for occurrence of a composite outcome of proximal thrombus extension or anticoagulant treatment initiation. Descriptive statistics were used to summarize characteristics of the study population. Characteristics were compared across outcome groups using inferential statistics. RESULTS: A total of 182 subjects were included, with 53 subjects (29.1%) experiencing the composite outcome. Of these, 12 (22.6%) experienced proximal thrombus extension and 41 (77.4%) initiated anticoagulant treatment. A prior history of venous thromboembolism (VTE) was significantly higher in those who experienced the composite outcome than in those who did not. CONCLUSIONS: Our results suggest that 70% of patients with serial CUS-monitored IDDVT did not experience thrombus extension or require anticoagulant treatment within 30 days of diagnosis, regardless of risk factors for proximal extension. Serial CUS monitoring may be a useful management strategy for IDDVT. A history of VTE may identify patients more likely to experience proximal thrombus extension or require anticoagulation.

A risk-stratified approach to venous thromboembolism prophylaxis with aspirin or warfarin following total hip and knee arthroplasty: A cohort study.

INTRODUCTION: Venous thromboembolism (VTE) and bleeding events following total knee and hip arthroplasty (TKA/THA) are associated with significant morbidity. Clinical guidelines recommend administration of pharmacologic VTE prophylaxis post-operatively, although controversy exists regarding optimal prophylactic strategies. METHODS: We performed a retrospective cohort study in patients who underwent elective TKA/TKA in an academic medical center. Patients were stratified by surgery type (TKA/THA) and VTE risk determined by a novel risk stratification protocol and compared pre- and post-protocol implementation. Patients received warfarin pre-protocol and either aspirin or warfarin post-protocol for VTE prophylaxis. Natural language processing identified VTE events and ICD codes were used to identify bleeding events, with all events validated manually. RESULTS: A total of 1379 surgeries were included for analysis, 839 TKAs and 540 THAs. Post-protocol implementation, 445 (94.1%) patients following TKA and 294 (97.4%) patients following THA received aspirin for VTE prophylaxis. A significant reduction in bleeding events (hazard ratio [HR] = 0.19, p = 0.048) was observed in low-risk THA patients treated with aspirin (post-protocol) compared patients treated with warfarin (pre-protocol). Bleeding events did not differ significantly between low-risk TKA patients treated with aspirin or warfarin. No significant differences in VTE events were observed following the protocol implementation. CONCLUSIONS: The use of a novel risk stratification system to guide VTE prophylaxis selection between aspirin or warfarin following TKA and THA appears safe and effective. Among low-risk patients, aspirin use was associated with fewer bleeding events following THA, without an observed increase in VTE events.

A comparison of natural language processing to ICD-10 codes for identification and characterization of pulmonary embolism.

INTRODUCTION: The 10th revision of the International Classification of Diseases (ICD-10) codes is frequently used to identify pulmonary embolism (PE) events, although the validity of ICD-10 has been questioned. Natural language processing (NLP) is a novel tool that may be useful for pulmonary embolism identification. METHODS: We performed a retrospective comparative accuracy study of 1000 randomly selected healthcare encounters with a CT pulmonary angiogram ordered between January 1, 2019 and January 1, 2020 at a single academic medical center. Two independent observers reviewed each radiology report and abstracted key findings related to PE presence/absence, chronicity, and anatomic location. NLP interpretations of radiology reports and ICD-10 codes were queried electronically and compared to the reference standard, manual chart review. RESULTS: A total of 970 encounters were included for analysis. The prevalence of PE was 13% by manual review. For PE identification, sensitivity was similar between NLP (96.0%) and ICD-10 (92.9%; p = 0.405), and specificity was significantly higher with NLP (97.7%) compared to ICD-10 (91.0%; p < 0.001). NLP demonstrated higher sensitivity (70.0% vs 16.5%, p < 0.001) and specificity (99.9% vs 99.4%, p = 0.014) for saddle/main PE recognition, and significantly higher sensitivity (86.7% vs 8.3%, p < 0.001) and specificity (99.8% vs 96.5%, p < 0.001) for subsegmental PE compared to ICD-10. CONCLUSIONS: NLP is highly sensitive for PE identification and more specific than ICD-10 coding. NLP outperformed ICD-10 coding for recognition of subsegmental, saddle, and chronic PE. Our results suggest NLP is an efficient and more reliable method than ICD-10 for PE identification and characterization.

Anticoagulant therapy management of venous thromboembolism recurrence occurring during anticoagulant therapy: a descriptive study.

Limited evidence exists regarding management of recurrent venous thromboembolism (VTE) that occurs during anticoagulant therapy. We aimed to describe patient characteristics, drug therapy management, and outcomes of patients with VTE recurrence during anticoagulant therapy. We identified 30 relevant episodes of VTE recurrence. Mean age was 48.9 (15.9) years, 56.7% were male, and 93.3% were White. Common VTE risk factors included cancer (46.6%), recent surgery (33.3%), and prolonged immobility (30.0%). At the time of recurrent VTE, 40.0% were receiving enoxaparin, 30.0% warfarin, and 23.3% direct oral anticoagulants. Potential causes for VTE recurrence included indwelling venous catheters (40.0%), cancer (33.3%), subtherapeutic anticoagulation (26.7%), and nonadherence (23.3%). Recurrent VTE management strategies included switching anticoagulants (26.7%), increasing anticoagulant dose (20.0%), temporarily adding enoxaparin or unfractionated heparin to oral anticoagulation therapy (13.3%), or no change in anticoagulation therapy (43.3%). Only four adverse 90-day outcomes occurred among 17 patients who received anticoagulant therapy changes in response to VTE recurrence, whereas eight adverse outcomes occurred in the 13 patients who received no change in anticoagulation therapy in response to a recurrent VTE episode (P value 0.04). Regardless of the potential etiology of recurrent VTE during anticoagulant therapy; switching anticoagulants, temporarily adding injectable anticoagulants, or increasing anticoagulant intensity appears preferable to continuing current anticoagulant therapy unchanged.

Impact of Different Electronic Cohort Definitions to Identify Patients With Atrial Fibrillation From the Electronic Medical Record.

Background Electronic medical records (EMRs) allow identification of disease-specific patient populations, but varying electronic cohort definitions could result in different populations. We compared the characteristics of an electronic medical record-derived atrial fibrillation (AF) patient population using 5 different electronic cohort definitions. Methods and Results Adult patients with at least 1 AF billing code from January 1, 2010, to December 31, 2017, were included. Based on different electronic cohort definitions, we trained 5 different logistic regression models using a labeled training data set (n=786). Each model yielded a predicted probability; patients were classified as having AF if the probability was higher than a specified cut point. Test characteristics were calculated for each model. These models were then applied to the full cohort and resulting characteristics were compared. In the training set, the comprehensive model (including demographics, billing codes, and natural language processing results) performed best, with an area under the curve of 0.89, sensitivity of 0.90, and specificity of 0.87. Among a candidate population (n=22 000), the proportion of patients identified as having AF varied from 61% in the model using diagnosis or procedure International Classification of Diseases (ICD) billing codes to 83% in the model using natural language processing of clinical notes. Among identified AF patients, the proportion of patients with a CHA2DS2-VASc score ≥2 varied from 69% to 85%; oral anticoagulant treatment rates varied from 50% to 66% depending on the model. Conclusions Different electronic cohort definitions result in substantially different AF study samples. This difference threatens the quality and reproducibility of electronic medical record-based research and quality initiatives.

Vitamin K versus warfarin interruption alone in patients without bleeding and an international normalized ratio > 10.

BACKGROUND: Reversal of an international normalized ratio (INR) > 10 with vitamin K is recommended in patients experiencing bleeding; however, information on outcomes with reversal using vitamin K in non-bleeding patients is lacking. OBJECTIVE: To compare clinical and safety outcomes between non-bleeding patients receiving warfarin with an INR > 10 who did and did not receive a prescription for vitamin K. PATIENTS/METHODS: This was a retrospective cohort study conducted in an integrated health-care delivery system. Adult patients receiving warfarin therapy who experienced an INR > 10 without bleeding between 01/01/2006 and 06/30/2018 were included. Patients were assessed for an outpatient dispensing or in-office administration of vitamin K on the day of or the day after an INR > 10 and then clinically relevant bleeding, thromboembolism, all-cause mortality, and time to INR < 4 within the next 30 days. RESULTS: A total of 809 patients was included with 332 and 477 who were and were not dispensed vitamin K, respectively. Overall, mean patient age was 71.7 years, 60.1% were female and the mean INR was 10.4 at presentation. There were no differences between groups in 30-day rates of bleeding or thromboembolism (both P > .05). Patients dispensed vitamin K had a higher likelihood of mortality (15.1% versus 10.1%, P = .032, adjusted odds ratio = 1.63, 95% confidence interval 1.03 to 2.57). Overall, time to an INR < 4 was similar between groups. CONCLUSION: Vitamin K administration was not associated with improved clinical outcomes in asymptomatic patients with an INR > 10.

The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.

The role of dedicated anticoagulation management services (AMS) for patients receiving direct oral anticoagulant (DOAC) therapy is unclear. The objective of our study was to describe DOAC management in patients who were and were not managed by an AMS. We conducted a retrospective cohort study among patients with atrial fibrillation at the University of Utah Health (UUH) who received DOAC therapy between January 2013 and June 2016. Patients in the AMS group were managed by a pharmacist-led AMS whereas those in the non-AMS group were managed by other providers. The number and type of provider encounters and interventions related to DOAC therapy and a composite endpoint of thromboembolism, bleeding, and all-cause mortality were recorded. Overall, 90 and 370 patients were managed in the AMS and non-AMS groups, respectively. AMS group patients had greater chronic disease burden as measured by the Charlson comorbidity index. AMS group patients had more frequent DOAC-related encounters than non-AMS group patients but both groups had similar DOAC therapy intervention rates. Over half of patients in the AMS group received potentially duplicative interventions from their regular clinicians. The composite endpoint occurred in 18.9% and 13.5% of AMS and non-AMS group patients, respectively (p = 0.29). Patients managed by AMS providers were more complex and had more frequent encounters regarding their DOAC therapy than those managed by non-AMS providers. However, there was evidence of duplicative DOAC therapy management efforts. No difference between AMS and non-AMS groups in the composite clinical endpoint was detected.

Survey of current treatment practices for venous thromboembolism in patients with cystic fibrosis.

BACKGROUND: Patients with cystic fibrosis (CF) and venous thromboembolism (VTE) pose therapeutic challenges including potential drug interactions between CF-related therapies and anticoagulants. Despite these challenges, there are no recommendations for VTE management specific to patients with CF. Our objective was to describe VTE treatment practices among Cystic Fibrosis Foundation (CFF)-accredited care centers and affiliate programs in the United States. METHODS: An online survey was distributed to CF center directors. The survey included questions regarding centers' demographics and posed a series of hypothetical clinical scenarios to gather centers' VTE treatment practices including choice of anticoagulant, dosing practices, duration decisions, and monitoring efforts. Descriptive statistics were utilized to summarize the survey results. RESULTS: The survey response rate was 56.3%. Most centers reported treating zero to five VTE episodes per year. The following anticoagulants were used most often for VTE treatment: low-molecular-weight heparin (LMWH) (73.2%), apixaban (36.6%), warfarin (35.2%), rivaroxaban (33.8%), and unfractionated heparin (18.3%). On a scale of 0 to 100, the median confidence level in managing anticoagulant therapy was 50. Many centers expressed a desire for a CF-specific VTE treatment guideline. The most commonly cited challenging clinical situations were managing anticoagulant therapy complications (26.5%) and drug-drug interactions (21.3%). For common VTE scenarios, pediatric patients were most often treated with LMWH and warfarin, whereas adult patients were more often treated with apixaban or rivaroxaban. CONCLUSIONS: Survey results indicated CF care centers find managing VTE in patients with CF challenging and indicated that a CF-specific VTE treatment guideline would be helpful.

Direct oral anticoagulant plus antiplatelet therapy: prescribing practices and bleeding outcomes.

Concurrent antiplatelet therapy (APT) is common during warfarin therapy but is less well-documented during direct oral anticoagulant (DOAC) therapy. Combined anticoagulant and APT use has been associated with increased bleeding risk without providing additional protection against thrombosis. This study aimed to describe single-center prescribing rates of DOAC + APT as well as compare bleeding rates between DOAC monotherapy and DOAC + APT cohorts. Patients receiving DOAC therapy were evaluated for APT use at the time of hospital discharge. Patients were categorized into DOAC monotherapy and DOAC + APT cohorts. Primary outcomes included DOAC + APT prescribing rate as well as rates of major bleeding and clinically relevant non-major bleeding (CRNMB) within six months after hospital discharge. Secondary outcomes included rates of thromboembolism and all-cause mortality. Of 407 patients receiving DOAC therapy, 78 (19.2%) also received APT at hospital discharge. Common indications for APT included secondary cardiovascular event prevention (57.7%) and primary cardiovascular event prevention (29.5%). The indication for APT could not be determined in 12.8% of patients. The major bleeding rate was 1.3% for DOAC + APT and 1.2% for DOAC monotherapy (p = 0.95). The CRNMB rate was 10.2% for DOAC + APT and 6.4% for DOAC monotherapy (p = 0.23). Thromboembolism and mortality were infrequent in both cohorts. DOAC + APT was documented in approximately 1 of 5 patients. Adding APT to DOAC therapy did not significantly increase the major bleeding or CRNMB rates compared to DOAC monotherapy but the sample size limits drawing conclusions about the safety of these regimens. Targeting primary prevention or unclear indications for APT could be a focus of future interventions.

Real-world study of direct oral anticoagulant dosing patterns in patients with atrial fibrillation

BACKGROUND: Direct oral anticoagulants (DOACs) are preferred for stroke prevention in atrial fibrillation (AF). However, off-label doses have been associated with increased risk of adverse events. OBJECTIVE: The objective of this study was to compare the frequency and outcomes of labeled versus off-label DOAC dosing in patients with AF. METHODS: This retrospective cohort study included adults diagnosed with nonvalvular AF (NVAF), discharged from University of Utah Health on DOAC therapy between 7/1/2017 and 9/30/2017. The primary outcome was off-label DOAC dosing frequency, defined as dosing inconsistent with manufacturer labeling. Secondary outcomes included variables associated with off-label dosing and a composite of adverse events (major bleeding, thromboembolism, and all-cause mortality) in the 90 days following the index hospital discharge. RESULTS: Of 249 included patients, 16.1% were discharged with off-label dosing. Factors associated with off-label dosing included advanced age, lower body mass index, decreased renal function, use of rivaroxaban, and hepatic impairment. The majority of off-label patients (70%) received lower-than-recommended DOAC dosing. Prescriber rationale for off-label prescribing was documented in 25% of patients and included anti-Xa guided dosing, high risk for bleeding or thromboembolism, and prior history of on-therapy adverse events. The rate of adverse events between labeled and off-label DOAC doses was not statistically different (10.0% vs.6.7%, p = 0.299), although this is likely due to small sample size. CONCLUSIONS: Off-label DOAC prescribing for stroke prevention in NVAF at University of Utah Health was consistent or lower than previously published studies. Off-label dosing most often involved under-dosing of rivaroxaban. Future research should investigate the role of provider rationale and insight in optimizing DOAC therapy outcomes

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