Guideline-discordant dosing of direct-acting oral anticoagulants in the veterans health administration

Adam J. Rose*, Jong Soo Lee, Dan R. Berlowitz, Weisong Liu, Avijit Mitra, Hong Yu

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: Clear guidelines exist to guide the dosing of direct-acting oral anticoagulants (DOACs). It is not known how consistently these guidelines are followed in practice. Methods: We studied patients from the Veterans Health Administration (VA) with non-valvular atrial fibrillation who received DOACs (dabigatran, rivaroxaban, apixaban) between 2010 and 2016. We used patient characteristics (age, creatinine, body mass) to identify which patients met guideline recommendations for low-dose therapy and which for full-dose therapy. We examined how often patient dosing was concordant with these recommendations. We examined variation in guideline-concordant dosing by site of care and over time. We examined patient-level predictors of guideline-concordant dosing using multivariable logistic models. Results: A total of 73,672 patients who were prescribed DOACS were included. Of 5837 patients who were recommended to receive low-dose therapy, 1331 (23%) received full-dose therapy instead. Of 67,935 patients recommended to receive full-dose therapy, 4079 (6%) received low-dose therapy instead. Sites varied widely on guideline discordant dosing; on inappropriate low-dose therapy, sites varied from 0 to 15%, while on inappropriate high-dose therapy, from 0 to 41%. Guideline discordant therapy decreased by about 20% in a relative sense over time, but its absolute numbers grew as DOAC therapy became more common. The most important patient-level predictors of receiving guideline-discordant therapy were older age and creatinine function being near the cutoff value. Conclusions: A substantial portion of DOAC prescriptions in the VA system are dosed contrary to clinical guidelines. This phenomenon varies widely across sites of care and has persisted over time.

Original languageAmerican English
Article number1351
JournalBMC Health Services Research
Issue number1
StatePublished - 18 Dec 2021

Bibliographical note

Publisher Copyright:
© 2021, The Author(s).


  • Anticoagulants
  • Atrial fibrillation
  • Medication therapy management
  • Quality of health care


Dive into the research topics of 'Guideline-discordant dosing of direct-acting oral anticoagulants in the veterans health administration'. Together they form a unique fingerprint.

Cite this