Introduction
thrombotic, VTE, venous thromboembolism
ATRIAL FIBRILLATION (AF), ADVERSE DRUG EVENTS
Direct oral anticoagulant (DOAC) medication use is rapidly expanding for six million Americans with common thrombotic conditions. Atrial fibrillation (AF) and venous thromboembolism (VTE) are the leading indications for chronic anticoagulation therapy. Since 2010, four DOAC medications (apixaban, dabigatran, edoxaban, and rivaroxaban) have rapidly overtaken warfarin as the first-line therapy for AF and VTE [Despite their popularity, however, unsafe DOAC prescribing is common and dangerous. While initially heralded as easier to prescribe than warfarin, in real-world settings 10–20% of DOAC prescriptions do not follow the Federal Drug Administration (FDA) evidence-based package label instructions [World Health Organization 6 steps of rational prescribingWhile the evidence for how to safely prescribe DOAC medications is well-established, key barriers prevent consistent implementation. Categorized using the Consolidated Framework for Implementation Research (CFIR) [Theory-based implementation strategies may help to overcome these barriers to evidence-based DOAC prescribing. While more than 70 different implementation strategies have been identified by the Expert Recommendations for Implementing Change (ERIC) project [With respect to EHR tools for implementation, medication alerts are among the most commonly used. However, most medication alerts do not follow key design principles and as such fail to improve patient care. Studies have shown that well-designed medication alerts in the EHR can reduce adverse drug events by up to 50% [Medical informatics experts have proposed key design principles to address these issues (Table Medication alert design principles [This study seeks to develop and test two implementation strategies to improve evidence-based DOAC prescribing using a pragmatic comparative effectiveness implementation trial. Prescribers whose patients are receiving inappropriate DOACs will be randomized to different forms of implementation support, including well-designed medication alerts with or without opportunities for prescriber-pharmacist collaboration.