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.