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Multilevel Stewardship Intervention for Use of Anticoagulation-Antiplatelet Therapy
Jacob E Kurlander1,2, David Parra3, Von Moore4
1VA Ann Arbor Center for Clinical Management Research, Michigan.
JAMA Internal Medicine
|June 22, 2026
Summary
A quality improvement initiative successfully reduced overprescribed antiplatelet medications in patients taking direct oral anticoagulants (DOACs). This stewardship approach decreased potentially harmful combination antithrombotic therapy, especially in patients with stable coronary artery disease.
Area of Science:
- Pharmacology
- Clinical Pharmacy
- Health Services Research
Background:
- Overprescription of antiplatelet medications in patients taking direct oral anticoagulants (DOACs) increases major bleeding risk.
- The effectiveness of scalable antithrombotic stewardship initiatives is not well-established.
- Optimizing antithrombotic therapy is crucial for patient safety and effective treatment.
Purpose of the Study:
- To evaluate a multicomponent antithrombotic stewardship initiative aimed at reducing unnecessary antiplatelet use in DOAC patients.
- To assess the impact of educational outreach, EHR modifications, and electronic flagging on prescribing patterns.
Main Methods:
- Retrospective comparative interrupted-time-series analysis from July 2020 to July 2023.
- Intervention involved 7 Veterans Health Administration (VHA) health systems; 128 VHA systems served as controls.
- Multicomponent intervention included educational outreach, EHR changes, and pharmacist-facing electronic flags.
Main Results:
- Preintervention antiplatelet use was 26.1% in intervention sites and 30.1% in control sites.
- Antiplatelet use decreased significantly faster in intervention sites (-0.58 pp/6 months) compared to controls post-intervention.
- The greatest reduction was observed in patients with stable coronary artery disease (-2.1 pp/6 months).
Conclusions:
- A multicomponent antithrombotic stewardship initiative effectively reduced potentially harmful combination antithrombotic therapy.
- Educational outreach, EHR modifications, and electronic flags demonstrated additive effects.
- Multilevel interventions are important for promoting evidence-based antithrombotic prescribing.
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