title: Site-level variation in and practices associated with dabigatran adherence.
abstract: OBJECTIVE
  Unlike warfarin, which requires routine laboratory testing and dose adjustment, target-specific oral anticoagulants like dabigatran do not. However, optimal follow-up infrastructure and modifiable site-level factors associated with improved adherence to dabigatran are unknown.
  
  
  OBJECTIVE
  To assess site-level variation in dabigatran adherence and to identify site-level practices associated with higher dabigatran adherence.
  
  
  METHODS
  Mixed-methods study involving retrospective quantitative and cross-sectional qualitative data. A total of 67 Veterans Health Administration sites with 20 or more patients filling dabigatran prescriptions between 2010 and 2012 for nonvalvular atrial fibrillation were sampled (4863 total patients; median, 51 patients per site). Forty-seven pharmacists from 41 eligible sites participated in the qualitative inquiry.
  
  
  METHODS
  Site-level practices identified included appropriate patient selection, pharmacist-driven patient education, and pharmacist-led adverse event and adherence monitoring.
  
  
  METHODS
  Dabigatran adherence (intensity of drug use during therapy) defined by proportion of days covered (ratio of days supplied by prescription to follow-up duration) of 80% or more.
  
  
  RESULTS
  The median proportion of patients adherent to dabigatran was 74% (interquartile range [IQR], 66%-80%). After multivariable adjustment, dabigatran adherence across sites varied by a median odds ratio of 1.57. Review of practices across participating sites showed that appropriate patient selection was performed at 31 sites, pharmacist-led education was provided at 30 sites, and pharmacist-led monitoring at 28 sites. The proportion of adherent patients was higher at sites performing appropriate selection (75% vs 69%), education (76% vs 66%), and monitoring (77% vs 65%). Following multivariable adjustment, association between pharmacist-led education and dabigatran adherence was not statistically significant (relative risk [RR], 0.94; 95% CI, 0.83-1.06). Appropriate patient selection (RR, 1.14; 95% CI, 1.05-1.25), and provision of pharmacist-led monitoring (RR, 1.25; 95% CI, 1.11-1.41) were associated with better patient adherence. Additionally, longer duration of monitoring and providing more intensive care to nonadherent patients in collaboration with the clinician improved adherence.
  
  
  CONCLUSIONS
  Among nonvalvular atrial fibrillation patients treated with dabigatran, there was variability in patient medication adherence across Veterans Health Administration sites. Specific pharmacist-based activities were associated with greater patient adherence to dabigatran.
authors: Emory University School of Medicine, Atlanta, Georgia.
authors: Supriya
authors: S
authors: Shore
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado3University of Colorado, Aurora, Colorado4Colorado Cardiovascular Outcomes Research Consortium, Denver.
authors: P Michael
authors: PM
authors: Ho
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado4Colorado Cardiovascular Outcomes Research Consortium, Denver.
authors: Anne
authors: A
authors: Lambert-Kerzner
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado3University of Colorado, Aurora, Colorado4Colorado Cardiovascular Outcomes Research Consortium, Denver.
authors: Thomas J
authors: TJ
authors: Glorioso
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado3University of Colorado, Aurora, Colorado4Colorado Cardiovascular Outcomes Research Consortium, Denver.
authors: Evan P
authors: EP
authors: Carey
authors: Veterans Affairs, Pharmacy Benefits Management Services and Center for Medication Safety, Hines, Illinois.
authors: Fran
authors: F
authors: Cunningham
authors: Veterans Affairs, Pharmacy Benefits Management Services and Center for Medication Safety, Hines, Illinois.
authors: Lisa
authors: L
authors: Longo
authors: Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California7Western University of Health Sciences, Pomona, California.
authors: Cynthia
authors: C
authors: Jackevicius
authors: Bedford Veterabs Affairs Medical Center, Bedford, Massachusetts9Boston University, Boston, Massachusetts.
authors: Adam
authors: A
authors: Rose
authors: Veterans Affairs Palo Alto Health Care System, Palo Alto, California11Stanford University School of Medicine, Stanford, California.
authors: Mintu P
authors: MP
authors: Turakhia
mesh_terms: D000368:Aged; D000991:Antithrombins / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D001562:Benzimidazoles / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D000069604:Dabigatran; D016903:Drug Monitoring; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010353:Patient Education as Topic; D018579:Patient Selection; D010595:Pharmacists; D012189:Retrospective Studies; D014481:United States; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D000991:Antithrombins; D001562:Benzimidazoles; D015091:beta-Alanine; D000069604:Dabigatran