Appropriateness prescriptions of direct oral anticoagulants in hospital in 2023 in the older population: a prospective observational multicenter study

Background Direct oral anticoagulants (DOACs) are increasingly prescribed, particularly in outpatient settings by general practitioners. In older patients with polypharmacy, inappropriate DOAC prescribing represents a major patient safety concern, potentially leading to therapeutic failure or preventable harm. To assess the quality and safety of DOAC prescriptions at hospital admission and discharge among older adults in 2023. Secondary objectives were to identify factors associated with inappropriate prescribing, characterize underlying prescribing errors, and compare these findings with data from 2018. Methods We conducted a prospective, observational, multicentre study across three French university hospitals, including departments of cardiology, internal medicine, post-emergency, and acute geriatrics. Older adults who were taking DOACs prior to admission and hospitalized for >24 hours were consecutively enrolled between November 2022 and May 2023. Appropriateness was defined according to European Society of Cardiology (ESC) guidelines. Predictive factors were analyzed using logistic regression, and comparisons with 2018 data were made using χ² tests. Results Of 536 eligible patients (mean age 84.1± 8.5 years; 50.6% women), 421 were included in the primary analysis. Most received apixaban (70.1%) for atrial fibrillation (83.6%). Inappropriate prescriptions were identified in 32.0% on admission and 24.9% at discharge (p = 0.004). Age >80 years (OR=1.80, CI95%= 1.20-2.72) and serum creatinine >133 µmol/L (OR=1.84, CI95%= 1.13-2.98) were associated with admission inappropriateness; age >80 years remained a discharge risk factor (OR=2.71, CI95%= 1.63-4.61), while weight <60 kg was protective (OR=0.42, CI95%= 0.25-0.69). No significant changes were observed compared to 2018. Conclusions Inappropriate DOAC prescribing during hospital transitions remains common in older adults, driven by advanced age and impaired renal function. The absence of substantial improvement since 2018 suggests that further efforts to optimize DOAC prescribing are warranted. Future interventions, including pharmacist-led medication reviews and integrated prescribing tools, could be considered to improve DOAC prescribing appropriateness in older adults. Trial registration Clinical trial not applicable.