Direct oral anticoagulants (DOACs) for the treatment of acute venous thromboembolism (VTE) appear to be used more often than traditional therapies for patients in emergency departments (EDs) and in rural settings, according to the results of a recent study published in Clinical Therapeutics.

To compare and describe the use of DOACs with traditional therapies (parenteral anticoagulant with or without warfarin), Tammy J. Bungard, BSP, PharmD, of the University of Alberta in Canada, and colleagues retrospectively reviewed medical records of patients discharged with acute VTE from 16 institutions across 4 provinces in Canada between April 1, 2015, and March 31, 2016.

Institutions were categorized as academic-based (university associated), community-based (serving >50,000 people), or rural-based (serving <50,000 people). The study population included adults who were discharged directly from the ED or after hospitalization with acute deep venous thrombosis (DVT) or pulmonary embolism (PE). Patients who were receiving palliative care, breast feeding/pregnant, or who presented with atypical clots were excluded from the study.

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The study included 590 persons discharged from the ED and 809 persons discharged after hospitalization. Compared with patients discharged from the ED, patients who were hospitalized were older (56.8 years vs 63.8 years; P <.0001) and had more comorbidities, including history of cancer (17.9% vs 28.7%; P <.0001), pulmonary disease (6.9% vs 17.6%; P <.0001), and heart failure (1.7% vs 13.1%; P <.0001) than those who were discharged from the ED. Most patients in the hospitalized cohort were discharged with PEs (82.7%), while most of those in the ED cohort were discharged with DVT (62.8%; P <.0001).

DOACs were prescribed to patients in the ED cohort more often than those in the hospitalized cohort (51.4% vs 44.3%; P =.0042). DOACs were also prescribed more to those who had a lower risk of PE, according to the simplified Pulmonary Embolism Severity Index score, in both the ED (score 0 vs ≥1, 58.0% vs 26.5%; P <.0001) and hospitalized cohorts (57.1% and 35.7%; P <.0001).

DOACs were prescribed least often in academic settings (46.2%) and most often in rural settings (56.7%). The use of warfarin-based regimens was lowest in academic settings (35.3%), followed by community settings (51.2%), and then rural settings (45.8%).

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Limitations of the study included the retrospective design, that patient outcomes could not be assessed after release, and that factors contributing to hospitalization and length of stay were not assessed.

“Over time, use of DOACs is likely to increase, and patient factors (eg, those younger with fewer comorbidities) and health care contact (eg, place of discharge or availability of an ambulatory VTE clinic) will likely continue to influence practice patterns,” wrote the authors.

Disclosures: Some authors have declared affiliations with the pharmaceutical industry. Please refer to the original study for a full list of disclosures.


Bungard TJ, Ritchie B, Bolt J, Thomson P, Semchuk WM. Use of direct oral anticoagulants versus traditional therapies for acute venous thromboembolism after direct discharge from the emergency department or after hospitalization: an audit of 16 Canadian hospitals [published online April 10, 2020]. Clin Ther. doi: 10.1016/j.clinthera.2020.03.001