JAMA Intern Med. 2026 Jun 22. doi: 10.1001/jamainternmed.2026.2036. Online ahead of print.
ABSTRACT
IMPORTANCE: Antiplatelet medications are overprescribed in patients taking direct oral anticoagulants (DOACs), increasing their risk of major bleeding. The utility of potentially scalable antithrombotic stewardship approaches remains unknown.
OBJECTIVE: To evaluate a multicomponent antithrombotic stewardship initiative to reduce unnecessary antiplatelet use in patients prescribed DOACs.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used retrospective multiperiod comparative interrupted-time-series analysis from July 2020 to July 2023 to compare intervention and control sites. Participants were adults prescribed DOACs in the ambulatory setting. The interventions occurred in 7 Veterans Health Administration (VHA) health systems, while 128 other VHA health systems served as controls. Data were analyzed from July 2023 to March 2026.
INTERVENTION: In stage 1, lasting 9 months, intervention sites implemented educational outreach to clinicians and patients and changes to the electronic health record system. In stage 2, lasting 16 months, a clinical pharmacist-facing electronic flag identifying patients receiving antiplatelet therapy was added to a widely used electronic dashboard.
MAIN OUTCOMES AND MEASURES: Monthly site-level percentage of patients prescribed antiplatelet medications. The summary measure was the difference in the semiannual change in the outcome for intervention compared with control sites, controlling for preintervention trends. Subgroup analyses were performed based on antiplatelet indication.
RESULTS: This study found that preintervention antiplatelet use in patients prescribed DOACs was 26.1% (95% CI, 26.0%-26.1%) in the 7 intervention sites (27 588 patients; 704 females [2.6%]) and 30.1% (95% CI, 30.0%-30.2%) in 128 control sites (253 085 patients; 6481 females [2.6%]). Antiplatelet use decreased faster by an absolute -0.58 (95% CI, -0.95 to -0.22) percentage points (pp) per 6 months for intervention compared with control sites after the 2 interventions had been implemented. The initial set of interventions was associated with an absolute -0.29 (95% CI, -0.61 to 0.04) pp change per 6 months and later augmentation with the electronic flag was associated with an absolute -0.29 (95% CI, -0.61 to 0.03) pp change per 6 months. The combined interventions were associated with the greatest reduction in the subgroup of patients with stable coronary artery disease (absolute -2.1 [95% CI, -3.0 to -1.2] pp per 6 months, equivalent to a -5.5% additional change compared with the baseline prevalence in this group), for whom antiplatelet deimplementation is likely appropriate.
CONCLUSIONS AND RELEVANCE: This study found that the combined interventions were associated with a clinically meaningful reduction in potentially harmful combination antithrombotic therapy. The initial educational outreach and changes to the electronic health record and later augmentation with the electronic flag had additive effects, highlighting the importance of multilevel interventions to speed adoption of evidence-based antithrombotic prescribing.
PMID:42329643 | DOI:10.1001/jamainternmed.2026.2036
