Priorities, Approaches, and Performance for Outpatient Antithrombotic Stewardship: The ADAPT Project

Antithrombotic (AT) agents are widely used and highly effective but are frequently implicated in preventable adverse events. Despite growing interest in AT stewardship, the outpatient care environment lacks a standardized measurement infrastructure analogous to what has been achieved in antimicrobial stewardship. The authors sought to characterize current outpatient practices across five care process priorities (CPPs) and examine gaps between clinical monitoring and system-level tracking to support future quality measurement and benchmarking.

The researchers conducted a sequential explanatory mixed methods evaluation of established anticoagulation management clinics. A national cross-sectional survey was followed by semistructured interviews. The survey assessed the presence of clinical monitoring and capacity for system-level tracking for each CPP; interviews explored operational approaches, reach, facilitators, and barriers.

Among 45 responding sites, monitoring of CPPs was common in some or all clinics, but system-level tracking was substantially less prevalent, with marked heterogeneity by CPP and setting. Sites frequently reported having protocols in place, yet few described routine tracking of adherence to them. US Department of Veterans Affairs (VA) clinics consistently demonstrated systemwide tracking-notably higher performance for warfarin time in therapeutic range (TTR) and broader reach-whereas non-VA sites more often relied on manual, labor-intensive audits or case-by-case review. Interview narratives revealed that survey-reported monitoring often reflected informal checks without automated data capture, standardized feedback loops, or population-level reporting.

Outpatient AT stewardship practices show high variability and a pervasive gap between clinical monitoring and population-level tracking. Advancing from monitoring to tracking is a prerequisite for specification and implementation of quality measures and benchmarking. Priorities include governance, data automation, and operational support aligned with core stewardship elements to enable reliable, scalable measurement of AT safety and effectiveness.