Variation in Dabigatran Adherence | Journal Scan

Study Questions:

What is the site-level variation in dabigatran adherence and site-level practices associated with higher dabigatran adherence?


This was a mixed-methods study involving retrospective quantitative and cross-sectional qualitative data. A total of 67 Veterans Health Administration (VHA) sites with 20 or more patients filling dabigatran prescriptions between 2010 and 2012 for nonvalvular atrial fibrillation were sampled (4,863 total patients; median, 51 patients per site). Forty-seven pharmacists from 41 eligible sites participated in the qualitative inquiry. Site-level practices identified included appropriate patient selection, pharmacist-driven patient education, and pharmacist-led adverse event and adherence monitoring. The main outcomes measure was 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.


The median proportion of patients who were 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% confidence interval [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.


The authors concluded that among nonvalvular atrial fibrillation patients treated with dabigatran, there was variability in patient medication adherence across VHA sites.


This site-level analysis of patients who had atrial fibrillation treated with dabigatran reports variation in the patient proportion adherent to dabigatran across VHA sites. Furthermore, there was variation in management strategies, with some sites using pharmacists and others deferring management solely to clinicians. The primary finding is that appropriate patient selection was associated with better dabigatran adherence and pharmacist-led monitoring was associated with higher adherence, with a progressive increase in adherence with longer monitoring duration. It appears that site-level practices may provide modifiable targets to improve patient adherence to dabigatran, as opposed to patient characteristics that frequently are not modifiable.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents

Keywords: Atrial Fibrillation, Antithrombins, Benzimidazoles, beta-Alanine, Cooperative Behavior, Cross-Sectional Studies, Education, Pharmacy, Intensive Care, Medication Adherence, Patient Compliance, Patient Selection, Pharmacists, Retrospective Studies, Risk, Veterans Health

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