A Way to Successfully Rein in Unnecessary Blood Thinner Use

The country’s largest integrated health system found a way to clamp down on unnecessary antiplatelet use among patients on direct oral anticoagulants (DOACs).

In a quality improvement study, seven health systems within the Veterans Health Administration (VHA; Florida, Georgia, Puerto Rico, and the U.S. Virgin Islands) were subject to a multi-prong intervention comprising clinician education and an electronic, clinical flagging of antiplatelet use without burdening doctors.

Together, the two changes were associated with antiplatelet prescribing going down from 26.1% at baseline to 17.9% across these seven systems 25 months later. This was a significantly better reduction than the drop from 30.1% to 21.6% across control sites (difference of -0.58 percentage points per 6 months), according to a group led by Jacob Kurlander, MD, MS, of VA Ann Arbor Healthcare System in Michigan.

“Our study contributes to a growing evidence base for antithrombotic stewardship, which can improve [oral anticoagulation] appropriateness, decrease bleeding, and reduce hospitalizations. To put the clinical benefits in perspective, for every 12 patients with antiplatelet deimplementation, one major or clinically relevant nonmajor bleeding event can be prevented based on a meta-analysis of randomized trials,” they wrote in JAMA Internal Medicine.

“Altogether, these findings suggest that the initial and later augmenting interventions had complementary roles in reducing antiplatelet therapy and represent scalable strategies to improve evidence-based antithrombotic prescribing, while highlighting opportunities to increase future impact,” the authors concluded.

It is a known problem that antiplatelet medications are overprescribed in patients taking DOACs, increasing their risk of bleeding requiring an emergency room visit.

Kurlander’s group reported that at the VHA, DOAC users with stable coronary artery disease (CAD) had the greatest reduction in antiplatelet prescribing following the combined intervention — and this is a population for whom antiplatelet deimplementation is likely appropriate and recommended in current guidelines.

“[T]he reduction in inappropriate antiplatelet use across a health system would benefit many patients,” according to C. Seth Landefeld, MD, of the University of Alabama at Birmingham, and Michael A. Steinman, MD, of the University of California San Francisco.

“Extrapolating these findings to the approximately 20,000 VHA patients with stable CAD prescribed both a DOAC and an antiplatelet, the intervention would be expected to eliminate inappropriate antiplatelet use in approximately 460 patients annually, thereby preventing approximately 40 major or other clinically significant bleeds,” the pair wrote in an accompanying editorial.

Landefeld and Steinman emphasized the VHA intervention’s low disruption to clinicians while shifting alerts to a clinical pharmacist. “Although Kurlander et al did not measure the intervention outcomes in clinicians, the fact that the intervention was so effective suggests that it may have been embraced by clinicians because it did not increase their burden.”

“Given the prevalence of clinician burnout and recognition of the moral obligation to care for physicians as well as patients, system-based interventions such as that of Kurlander et al could be an innovative advance that not only improves patient care but also supports physicians themselves,” according to the editorialists.

The quality improvement study was a retrospective analysis of adults prescribed DOACs in the ambulatory setting, divided between seven VHA health systems that implemented the intervention (n=27,588) and 128 non-participating sites (n=253,085).

The two cohorts were just under 75 years of age on average and the vast majority were men (97.4%). Over 80% were white and over 90% urban residents. Of note, patients at intervention sites had fewer baseline prescriptions for apixaban (49.3% vs 66.8%) and more for dabigatran (25.8% vs 7.3%).

The VHA antiplatelet stewardship program progressed in two stages:

• Stage 1 (lasting 9 months): educational outreach to clinicians and patients and changes to the electronic health record system
• Stage 2 (16 months): a clinical pharmacist-facing electronic flag identifying patients receiving antiplatelet therapy was added to a widely used electronic dashboard, plus continuation of stage 1 changes

Each stage was associated with an absolute -0.29 percentage point change in antiplatelet prescribing per 6 months, indicating their additive effects, according to Kurlander’s group.

However, the researchers acknowledged that the study could not capture any undocumented over-the-counter aspirin use.

Another limitation is the unknown generalizability of these results to other settings.

“The VHA is unusual in its systemness: for example, VHA already provides systemwide antithrombotic stewardship by clinical pharmacists across over 1,000 outpatient clinics. Thus, dissemination outside VHA has huge potential but would likely require substantial adaptation and tailoring for implementation in other settings,” according to Landefeld and Steinman.