2026 Eastern States Conference

​​​​Title:
Impact of clinical pharmacy involvement in patients naïve to direct oral anticoagulants (DOACs)

Authors:
Darla Khouri (PharmD), Kristen Fink (PharmD, BCPS, BCACP, CDES), Brandon Biggs (PharmD), Seema Ledan (PharmD)

Objective:
Identify the preferred anticoagulant options for patients requiring long-term anticoagulation therapy

Self Assessment Question:
True or False: Direct oral anticoagulants (DOACs) are the preferred first‑line anticoagulants for most patients with non‑valvular atrial fibrillation

Background:
This study evaluates the impact of pharmacist intervention during direct oral anticoagulant (DOAC) initiation at Kaiser Permanente Mid-Atlantic States and its impact on medication adherence and adverse events.

Methods:
A report of patients who initiated DOAC therapy between January 1, 2024 to March 31, 2025 was compiled and patients were divided into two groups: those with a pharmacy consult referral within 30 days of DOAC initiation and those without. A randomized sample of 200 patients from each group was reviewed. The primary objective was to assess adherence to DOAC therapy, measured by proportion of days covered (PDC) of ≥80% within the first 6 months of initiation. Secondary outcomes included percentage of patients who experienced a serious bleeding event, thromboembolic (TE) events, and incidence of adverse effects outside of bleeding and TE events. A retrospective chart review was done within Kaiser Permanente Health Connect to assess the endpoints using medical record numbers. The chi-square test of independence was performed for statistical analysis.

Results:
Most patients in the study received DOAC therapy for atrial fibrillation, pulmonary embolism (PE), or deep vein thrombosis (DVT). Dabigatran was the most prescribed DOAC. A significantly greater number of patients in the pharmacist intervention group achieved a PDC ≥80% (χ²= 7.3; P = .007). The pharmacist intervention group had a mean PDC of 91.3% within the first 6 months of DOAC initiation, compared with a PDC of 84.4% in the no intervention group. Secondary outcomes, including serious bleeding events, serious thromboembolic events, and other adverse events did not differ significantly between groups (P=0.12, P=0.59, respectively).

Conclusion:
Patients receiving clinical pharmacist intervention at the start of DOAC therapy demonstrated a statistically significant improvement in PDC compared to those who did not receive counseling. This study indicates that pharmacist intervention at DOAC initiation improved patient adherence as measured by PDC. Although safety outcomes did not differ significantly between groups, pharmacists should continue to emphasize safety considerations when counseling patients on DOAC therapy.