Pharmacist-led interventions in general practice on the use of oral anticoagulants

Background and objective: Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for an increasing proportion of OAC for patients with AF. The challenges of prescribing DOACs in established AF are widely reported, as are inappropriate dosing of DOACs and bleed risk review and management in primary care. This investigates the effectiveness of pharmacist-led interventions in general practice managing of OAC therapies in AF. Method: A retrospective cohort study screening pharmacist-led interventions recorded in electronic health records of men and women with atrial fibrillation in central Bradford, West Yorkshire, England, between November 2018 and December 2019. A total of 616 patients with a confirmed diagnosis of AF and on the participant practices’ AF Quality and Outcomes Framework (QOF) register were included in this study. AF management and DOAC education were provided to the pharmacists. Comparisons were made to the pre-intervention and post-intervention groups to determine the effectiveness of the pharmacist-led intervention. Prior to the start of data collection, a pharmacist-led intervention was developed and implemented. Main outcome measures: This data was analysed to identify and describe pharmacist-led interventions on: (1) those with established AF and not on OAC; (2) inappropriate prescriptions for DOACs; and (3) HAS-BLED scores. Results: Overall, 76% of patients received OAC therapy, and 48% received DOACs. The pharmacist-led intervention increased DOAC prescribing of 6% (p = 0.03). Inappropriate DOAC was identified in 24% of DOACs pre-intervention, underdosed (10%) and overdosed (15%), according to DOAC dosing criteria, which reduced to 0.9% of all DOAC prescribing post-intervention, underdosed (0.9%, p = 0.09) and overdosed (0.6%, p = 0.01). Pharmacist-led interventions to address the modifiable aspects of the HAS-BLED bleed risk scores were undertaken in 12% of patients on DOACs. Mean HAS-BLED scores were calculated and compared pre-intervention to post-intervention, a reduction from 3.00 vs 2.22 (p < 0.01). Successful transition from VKA therapy to DOACs was achieved in 25.71% of all patients on VKA therapy (pre-intervention). Conclusion: Overall, pharmacist-led interventions in the management of OAC therapy in general practice were found to increase OAC rates in this patient group and, significantly, effective in identifying and managing inappropriate DOAC prescribing. Pharmacists can make impactful interventions to manage the modifiable risk factors of a patient’s bleeding risk and can work within general practice teams to successfully transition VKA therapy to DOAC therapy, in line with guidelines and best practice.