Potentially inappropriate prescribing of direct-acting oral anticoagulants in the veterans health administration

Objectives: Little is known about variation in rate of uptake or potentially inappropriate prescribing of non-warfarin direct-acting oral anticoagulants (DOACs). Our objective was to examine variations in overall use, and potentially inappropriate use, of DOACs across sites within the Veterans Health Administration (VA). Study Design: Longitudinal database study. Methods: We examined 32,719 unique patients who received a DOAC from 1 of the 130 VA sites of care between October 1, 2010, and September 30, 2014 (fiscal year [FY] 2011-FY2014). We examined the growth of DOAC use over time, and how it varied by site. We examined the proportion of patients receiving DOACs who were potentially inappropriate recipients, because of the presence of a prosthetic heart valve or insufficient renal function. Results: Use of DOACs within VA increased, with more initial prescriptions in FY2014 (18,369 prescriptions) than all previous years combined (14,350). This use was uneven by site; the top 10 sites collectively accounted for 26% of DOAC prescriptions in FY2014, while the bottom 10 sites accounted for 0.6%. Overall, 4.58% of DOAC prescriptions were potentially inappropriate: 1.59% because of a prosthetic heart valve, and 3.04% because of insufficient renal function. The rate of inappropriate prescribing varied widely among sites, from a low of 0% (3 sites) to a high of 12.6%. Conclusions: Uptake of DOACs within VA is accelerating but is uneven across sites. While potentially inappropriate prescribing of DOACs is relatively uncommon, it varies among sites from completely absent to as high as 12.6% of prescriptions. Understanding this variation will have implications for pharmacy budgets and for patient safety.