Outcomes
The primary outcome was the percentage of patients with an inappropriate
DOAC initiated at or continued during hospital admission together with
the identification of determinants associated with DOAC under- and
overdosing. Similar to our previous study 3,
rivaroxaban was used as the reference category. Secondary outcomes
included the quantification of the physicians’ acceptance and
implementation rate of the clinical pharmacists’ interventions as well
as the documentation of their non-acceptance and/or non-implementation.
An inappropriate DOAC dose was defined as a deviation from the
recommended dose in the SmPC. Underdosing was defined as the prescribing
of a reduced DOAC dose despite the patient not meeting the dose
reduction criteria. Overdosing was defined as the prescribing of the
standard DOAC dose despite the patient meeting the dose reduction
criteria. A contraindication was defined as a situation for which the
prescription of the DOAC was inadvisable.
If an intervention by a clinical pharmacist was deemed necessary, the
prescribing hospital physician was contacted by telephone after which
the pharmacists’ recommendations were documented in the patient’s
electronic medical record. General practitioners (GP) and/or community
pharmacists involved in the patient’s care were contacted if the
prescribing hospital physician was unreachable, when more information
was needed, or in case the patient was already discharged.