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An Intervention to Reduce Antiplatelet Use without Gastroprotection in Patients Using Warfarin: The AEGIS Cluster
Jacob E Kurlander1,2,3, Danielle Helminski1, Xueting Tao4
1Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States.
Insights
A multicomponent intervention reduced unnecessary antiplatelet use in warfarin patients. This clinician notification with nurse facilitation (CNNF) strategy increased medication changes, lowering gastrointestinal bleeding risk.
Area of Science:
- Clinical Pharmacy
- Pharmacology
- Patient Safety
Background:
- Many patients on anticoagulants like warfarin also take antiplatelet medications.
- This combination, without gastroprotection (e.g., proton pump inhibitors - PPIs), significantly elevates the risk of gastrointestinal bleeding.
- Current prescribing practices often fail to adequately address this high-risk medication overlap.
Purpose of the Study:
- To assess the effectiveness of a clinician notification with nurse facilitation (CNNF) intervention.
- To reduce the high-risk co-prescription of antiplatelet agents in warfarin patients not receiving a PPI.
- To improve patient safety by mitigating gastrointestinal bleeding risks.
Main Methods:
- A multicomponent intervention involving electronic clinician notifications and nurse facilitation was implemented.
- Nurses identified patients on warfarin and antiplatelets without PPIs, recommending medication review.
- Outcomes measured included self-reported antiplatelet discontinuation or PPI initiation, and documented clinician recommendations.
Main Results:
- The CNNF intervention significantly increased the odds of patients discontinuing antiplatelet therapy or initiating a PPI (aOR 5.76).
- A modified completer analysis showed an even stronger effect (aOR 43.6).
- Clinician recommendations for medication changes were substantially higher in the intervention group (68.2% vs 0.9%).
Conclusions:
- The CNNF intervention is effective in prompting necessary medication adjustments for patients on warfarin and antiplatelets.
- This strategy successfully led to either antiplatelet discontinuation or PPI initiation, enhancing patient safety.
- Targeted interventions can improve prescribing practices and reduce medication-related adverse events.
Abstract:
Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding.To evaluate the effectiveness of a multicomponent intervention-clinician notification with nurse facilitation (CNNF)-in reducing high-risk use of antiplatelet medications in patients taking warfarin without a proton pump inhibitor (PPI).For patients in the CNNF group, nurses sent electronic messages to clinicians identifying patients with high-risk antiplatelet use, recommending consideration of either antiplatelet discontinuation or PPI initiation, and offering to facilitate any medication changes. The primary outcome was the percentage of patients who self-reported either discontinuing antiplatelet therapy or initiating a PPI at 7 to 10 weeks. The secondary outcome was the percentage of patients with a documented clinician recommendation to make such a medication change.Among 220 patients, CNNF was associated with increased odds of discontinuing antiplatelet therapy or initiating a PPI in the intention-to-treat analysis (adjusted odds ratio [aOR] 5.76, 95% CI 2.54, 13.05). The effect was stronger in a modified completer analysis (n = 126, aOR 43.6, 95% CI 6.56, 289.88). The intervention was also associated with increased odds of a clinician recommendation for a medication change (75/110 [68.2%] versus 1/110 [0.9%], log aOR 19.86, 95% CI 10.63, 29.09). Surgeons and proceduralists were less likely to recommend medication changes relative to other clinicians (log aOR -16.08, 95% CI -23.34, -8.82).The multicomponent intervention effectively led to antiplatelet discontinuation or PPI initiation in patients initially prescribed warfarin-antiplatelet therapy without gastroprotection.
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