A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high-risk cardiovascular patients at our institution.
OBJECTIVE: The aim of this study was to evaluate prescribing practices for elderly patients started on apixaban in multiple practice settings.<br/> DESIGN: Retrospective, chart review.<br/> SETTING: One outpatient and three inpatient settings in Arizona and Massachusetts.<br/> PATIENT, PARTICIPANTS: Patients who received a new order for apixaban between July 1, 2015, and December 31, 2016. Inclusion criteria included adults 65 years of age and older who were receiving apixaban for atrial fibrillation or venous thromboembolism (VTE) at a current treatment dose.<br/> There were 1,045 patients included, the average age was 78 years, 52% were male, and 90% had atrial fibrillation.<br/> MAIN OUTCOME MEASURE: Appropriate prescribing of apixaban based on Food and Drug Administration (FDA)-labeling (age, weight, serum creatinine).<br/> RESULTS: Six patients who were on hemodialysis were excluded from the analysis, leaving 1,039 patients to be analyzed. 16.2% (168/1,039) of patients had an incorrect dose of apixaban prescribed based on their indication. Of those, 75% (126/168) were taking the medication for atrial fibrillation and 25% (42/168) for VTE. For those with atrial fibrillation (n = 126), the majority of inappropriate orders resulted from doses that were lower than indicated (113/126).<br/> CONCLUSION: This research suggests that elderly patients may receive inappropriately lower doses of apixaban than indicated, which may decrease the effectiveness of the medication. This research supports the fact that pharmacists can play a vital role in anticoagulation stewardship by verifying apixaban doses for accuracy.
Since Food and Drug Administration approval of dabigatran in 2010, direct oral anticoagulants (DOACs) have been alternatives to warfarin for patients who are at risk for cardioembolic complications of nonvalvular atrial fibrillation. Unfortunately, there are limited safety data available on the use of these newer agents in older adults, particularly risks of gastrointestinal, intracranial, and major bleeding (as defined by the International Society on Thrombosis and Haemostasis) in those 75 years of age and older. The purpose of this manuscript is to provide a review of available literature regarding the risk of bleeding in older adults for each DOAC based on available retrospective cohort, secondary, and subgroup analyses, and to highlight the need for additional safety information in this population.
OBJECTIVE: To describe two innovative practice models that expand pharmacy services within a nursing facility's transitional care unit (TCU) to meet the needs of patients transitioning to subacute or community care. SETTING: TCU in a hospital-based vs. a community-based facility. PRACTICE DESCRIPTION: The two TCUs involved in these practices differ in that one is hospital-owned and the other is community-based and run by a nonprofit organization. Patients involved in the models are those who have been admitted to the TCU from a hospital and will eventually return home to the community. PRACTICE INNOVATION: Pharmacy services beyond the federally required, monthly drug regimen review are described, including pharmacist-conducted medication reconciliation, which identifies the drugs the patient is taking on admission and those prescribed before discharge from the TCU. Post-TCU discharge follow-up is also provided via telephone call or home visit. MAIN OUTCOME MEASUREMENTS: Description of practice models. RESULTS: Timely medication reconciliation and review on TCU admission is key to safe medication use during transitions of care. Incorporating pharmacy students and residents can promote awareness of the service. Partnerships with health systems and colleges or schools of pharmacy can provide financial support of these innovative practice models. CONCLUSION: Pharmacist-driven medication reconciliation and review can improve medication safety across transitions of care involving TCUs. Research is needed to evaluate the impact of these models on outcomes before they are replicated.
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