Highlight
The study demonstrates that a multilevel stewardship approach, including clinician and patient education, electronic health record (EHR) modifications, and pharmacist-oriented electronic flags, effectively reduces unnecessary antiplatelet usage in patients prescribed direct oral anticoagulants (DOACs). This intervention notably decreased combined antithrombotic therapy in a high-risk population across Veterans Health Administration (VHA) sites, with the greatest impact in stable coronary artery disease patients.
Study Background
Direct oral anticoagulants (DOACs) have become standard for thromboembolism prevention and treatment. However, concomitant use of antiplatelet therapy without a strong indication can increase major bleeding risk without additional ischemic benefit. Despite guideline recommendations, antiplatelet medications are often overprescribed among DOAC users, posing an unmet clinical need to optimize antithrombotic regimens and improve patient safety. Scalable stewardship interventions to address this overuse, particularly in ambulatory settings, have not been well studied.
Study Design
This quality improvement study employed a retrospective multiperiod comparative interrupted-time-series design from July 2020 to July 2023. It included adult outpatients prescribed DOACs across the Veterans Health Administration network. Seven intervention sites implemented a two-stage, multicomponent stewardship program, and 128 VHA sites served as controls.
Stage 1 (9 months) involved educational outreach targeted at clinicians and patients plus changes to the EHR aimed at prescribing practices. Stage 2 (16 months) introduced a pharmacist-facing electronic flag integrated into an existing clinical dashboard to identify patients concurrently prescribed antiplatelet agents. The primary outcome was the monthly percentage of DOAC-treated patients also prescribed antiplatelet therapy at the site level.
Key Findings
Baseline antiplatelet use in DOAC users was 26.1% in intervention sites (27,588 patients; 2.6% female) and 30.1% in control sites (253,085 patients; 2.6% female). Following interventions, antiplatelet use decreased more rapidly at intervention sites, with an absolute decline of 0.58 percentage points per six months compared with controls (95% CI, -0.95 to -0.22).
The initial educational and EHR modifications contributed an absolute reduction of 0.29 percentage points every six months, which was further augmented by the pharmacist-focused electronic flag yielding an additional 0.29 percentage points reduction. Thus, the interventions had additive effects.
Subgroup analyses indicated the most pronounced impact in patients with stable coronary artery disease, with an absolute reduction of 2.1 percentage points per six months (95% CI, -3.0 to -1.2), corresponding to a 5.5% greater decline relative to baseline prevalence. This subgroup was identified as appropriate for antiplatelet deimplementation.
These reductions in combined therapy are clinically important given the increased bleeding risk documented with unnecessary antiplatelet use in patients already anticoagulated with DOACs.
Expert Commentary
This study underscores the value of multilevel stewardship interventions that combine education, health information technology enhancements, and clinical pharmacist involvement to optimize evidence-based prescribing. The additive effect of augmenting initial interventions with an electronic alert highlights the necessity of sustained, multi-pronged approaches to change entrenched prescribing behaviors.
While limited to VHA ambulatory settings with mostly male patients, the findings are likely generalizable to similar integrated health systems. Future research could evaluate patient-centered outcomes such as bleeding events and ischemic complications post-deimplementation. Integration with clinical decision support tools and extension to other high-risk populations could further improve antithrombotic safety.
Conclusion
Appropriate deimplementation of antiplatelet agents in patients receiving DOAC therapy can be achieved through structured antithrombotic stewardship that includes education, electronic health record optimization, and pharmacist-led identification strategies. Such multilevel interventions are feasible and yield meaningful reductions in potentially harmful combination therapy, as exemplified in this large-scale Veterans Health Administration initiative.
Funding and Clinical Trials Registration
The study was conducted within the Veterans Health Administration system as a quality improvement initiative. No external funding or clinical trial registration information was reported.
References
1. Kurlander JE, Parra D, Moore V, et al. Multilevel Stewardship Intervention for Use of Anticoagulation-Antiplatelet Therapy. JAMA Internal Medicine. 2026; PMID: 42329643.
2. January CT, et al. 2019 AHA/ACC/HRS Focused Update on Antithrombotic Therapy for Atrial Fibrillation. Circulation. 2019.
3. Lopes RD, et al. Risks of Combined Antiplatelet and Anticoagulant Therapy. Circ Cardiovasc Qual Outcomes. 2020.
