{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T02:59:42Z","timestamp":1772593182149,"version":"3.50.1"},"reference-count":20,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2023,12,23]],"date-time":"2023-12-23T00:00:00Z","timestamp":1703289600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>The direct anticoagulants (DOACs), apixaban and rivaroxaban, are used for extended-phase treatment of venous thromboembolism (VTE) and have labeling for dose reduction for this indication. The objective of this study was to better understand primary care clinician prescribing patterns of apixaban and rivaroxaban for extended-phase anticoagulation. We conducted a 21-question survey targeting members of the American College of Physicians and United States Veterans Administration anticoagulation management services. Survey questions covered prescribing behaviors for dose reduction of apixaban and rivaroxaban for extended VTE treatment, as well as questions related to the respondent\u2019s practice setting. We used logistic regression to assess associations between demographics and prescribing behaviors. We used k-means clustering to identify distinct groups of prescribing patterns. Among 227 respondents, most were attending physicians (60%) and one-third (34%) practiced in internal medicine or primary care. Most (59%) indicated they dose-reduced DOACs. Hospitalists (no outpatient care) were least likely to dose-reduce (OR 0.09 [95% CI 0.03\u20130.22]), as well as early-career clinicians (0.53 [0.30\u20130.91]). Pharmacists and clinicians who treat over 500 VTE patients annually were most likely to dose reduce (6.4 [2.9\u201316.3]), (2.9 [1.5\u20136.0]), respectively. We identified five clusters of dosing behaviors and characterized clinician makeup. Clusters were primarily differentiated by frequency of dose reduction, DOAC preference, and temporary re-escalation of doses. We identified clinician characteristics that are associated with dose-reduction prescribing behaviors; these analyses provide insight into where targeted interventions, such as protocolization and education, would be most beneficial.<\/jats:p>","DOI":"10.3390\/jcm13010096","type":"journal-article","created":{"date-parts":[[2023,12,24]],"date-time":"2023-12-24T20:49:27Z","timestamp":1703450967000},"page":"96","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Primary Care Clinicians\u2019 Prescribing Patterns of Reduced-Dose Direct Oral Anticoagulants for Extended-Phase Venous Thromboembolism Treatment"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1180-4448","authenticated-orcid":false,"given":"Danielle","family":"Groat","sequence":"first","affiliation":[{"name":"Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT 84107, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karlyn","family":"Martin","sequence":"additional","affiliation":[{"name":"Division of Hematology\/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2392-7365","authenticated-orcid":false,"given":"Rachel","family":"Rosovsky","sequence":"additional","affiliation":[{"name":"Division of Hematology\/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0433-7845","authenticated-orcid":false,"given":"Kristen","family":"Sanfilippo","sequence":"additional","affiliation":[{"name":"Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manila","family":"Gaddh","sequence":"additional","affiliation":[{"name":"Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30307, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1171-0548","authenticated-orcid":false,"given":"Lisa","family":"Baumann Kreuziger","sequence":"additional","affiliation":[{"name":"Blood Research Institute, Versiti, Milwaukee, WI 53226, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9093-9622","authenticated-orcid":false,"given":"Elizabeth","family":"Federici","sequence":"additional","affiliation":[{"name":"Penn State Hershey Medical Center, Hershey, PA 17033, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2522-2705","authenticated-orcid":false,"given":"Scott","family":"Woller","sequence":"additional","affiliation":[{"name":"Department of Medicine, Intermountain Medical Center, Murray UT 84107, USA"},{"name":"Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,12,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e545","DOI":"10.1016\/j.chest.2021.07.055","article-title":"Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report","volume":"160","author":"Stevens","year":"2021","journal-title":"Chest"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"4693","DOI":"10.1182\/bloodadvances.2020001830","article-title":"American Society of Hematology 2020 guidelines for management of venous thromboembolism: Treatment of deep vein thrombosis and pulmonary embolism","volume":"4","author":"Ortel","year":"2020","journal-title":"Blood Adv."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Guidelines on diagnosis and management of acute pulmonary embolism (2000). Task Force on Pulmonary Embolism, European Society of Cardiology. Eur. Heart J., 21, 1301\u20131336.","DOI":"10.1053\/euhj.2000.2250"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1093\/eurheartj\/ehz405","article-title":"2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)","volume":"41","author":"Konstantinides","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_5","unstructured":"(2020, December 15). ELIQUIS Package Insert. Available online: https:\/\/packageinserts.bms.com\/pi\/pi_eliquis.pdf."},{"key":"ref_6","unstructured":"(2019, October 03). XARELTO Package Insert. 2021. Package Insert. Available online: http:\/\/www.janssenlabels.com\/package-insert\/product-monograph\/prescribing-information\/XARELTO-pi.pdf."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1056\/NEJMoa1302507","article-title":"Oral apixaban for the treatment of acute venous thromboembolism","volume":"369","author":"Agnelli","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1056\/NEJMoa1207541","article-title":"Apixaban for extended treatment of venous thromboembolism","volume":"368","author":"Agnelli","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1287","DOI":"10.1056\/NEJMoa1113572","article-title":"Oral rivaroxaban for the treatment of symptomatic pulmonary embolism","volume":"366","author":"Buller","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1056\/NEJMoa1700518","article-title":"Rivaroxaban or Aspirin for Extended Treatment of Venous Thromboembolism","volume":"376","author":"Weitz","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2505","DOI":"10.1007\/s11606-020-05904-0","article-title":"Oral anticoagulant utilization in the United States and United Kingdom","volume":"35","author":"Colacci","year":"2020","journal-title":"J. Gen. Int. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1055\/s-0040-1712098","article-title":"Direct Oral Anticoagulants for the Treatment of Acute Venous Thromboembolism Associated with Cancer: A Systematic Review and Meta-Analysis","volume":"120","author":"Giustozzi","year":"2020","journal-title":"Thromb. Haemost."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1007\/s11239-023-02774-1","article-title":"DOAC compared with warfarin for VTE in patients with obesity: A retrospective cohort study conducted through the VENUS network","volume":"55","author":"Martin","year":"2023","journal-title":"J. Thromb. Thrombolysis"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1874","DOI":"10.1111\/jth.15358","article-title":"Use of direct oral anticoagulants in patients with obesity for treatment and prevention of venous thromboembolism: Updated communication from the ISTH SSC Subcommittee on Control of Anticoagulation","volume":"19","author":"Martin","year":"2021","journal-title":"J. Thromb. Haemost."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Luca, F., Oliva, F., Abrignani, M.G., Di Fusco, S.A., Parrini, I., Canale, M.L., Giubilato, S., Cornara, S., Nesti, M., and Rao, C.M. (2023). Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J. Clin. Med., 12.","DOI":"10.3390\/jcm12185955"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1111\/jphs.12276","article-title":"Characterizing pharmacist prescribers in Alberta using cluster analysis","volume":"10","author":"Faruquee","year":"2019","journal-title":"J. Pharm. Health Serv. Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e12740","DOI":"10.1002\/rth2.12740","article-title":"Physician perceptions and use of reduced-dose direct oral anticoagulants for extended phase venous thromboembolism treatment","volume":"6","author":"Groat","year":"2022","journal-title":"Res. Pract. Thromb. Haemost."},{"key":"ref_18","first-page":"100","article-title":"Algorithm AS 136: A k-means clustering algorithm","volume":"28","author":"Hartigan","year":"1979","journal-title":"J. Roy. Stat. Soc. Ser. C"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/0377-0427(87)90125-7","article-title":"Silhouettes: A graphical aid to the interpretation and validation of cluster analysis","volume":"20","author":"Rousseeuw","year":"1987","journal-title":"J. Comp. App. Math."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1056\/NEJMoa035422","article-title":"Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism","volume":"349","author":"Kearon","year":"2003","journal-title":"N. Engl. J. Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/1\/96\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:41:07Z","timestamp":1760132467000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/1\/96"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,12,23]]},"references-count":20,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,1]]}},"alternative-id":["jcm13010096"],"URL":"https:\/\/doi.org\/10.3390\/jcm13010096","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,12,23]]}}}