Multilevel Antithrombotic Stewardship Program Reduces Unnecessary Antiplatelet Use in DOAC Patients: JAMA
USA: Researchers found in a quality improvement study that a multilevel antithrombotic stewardship program significantly reduced potentially harmful combination antithrombotic therapy, particularly unnecessary antiplatelet use, among patients receiving direct oral anticoagulants (DOACs), especially those with stable coronary artery disease (CAD).
The intervention combined educational outreach, electronic health record (EHR) modifications, and clinical pharmacist–facing electronic alerts, with each component contributing substantially to the observed improvement. These findings highlight the complementary value of clinician education and EHR-based decision support in accelerating the adoption of evidence-based prescribing practices and enhancing the safety of high-risk antithrombotic regimens.
The study, published in JAMA Internal Medicine, was led by Jacob E. Kurlander and colleagues. The researchers sought to determine whether a scalable, multicomponent antithrombotic stewardship initiative could reduce unnecessary antiplatelet prescribing among patients already receiving DOAC therapy, a combination that increases bleeding risk when used without a clear clinical indication.
For this purpose, the investigators conducted a quality improvement study across the Veterans Health Administration (VHA) system. Using a retrospective multiperiod comparative interrupted-time-series design, they analyzed data collected between July 2020 and July 2023. Seven VHA health systems implemented the stewardship interventions, while 128 VHA health systems served as controls. The analysis included adults prescribed DOACs in outpatient settings.
The intervention was introduced in two phases. During the first nine months, clinicians and patients received educational outreach, and modifications were made to the EHR to support appropriate prescribing decisions. In the second phase, spanning 16 months, a pharmacist-focused electronic alert was incorporated into a commonly used clinical dashboard to identify patients receiving concomitant antiplatelet therapy.
The study led to the following findings:
- At baseline, antiplatelet therapy was used by 26.1% of patients receiving DOACs at intervention sites and 30.1% at control sites.
- After implementation of the stewardship program, antiplatelet use declined significantly faster at intervention sites than at control sites.
- The intervention was associated with an additional reduction of 0.58 percentage points in antiplatelet prescribing every six months compared with control sites.
- Educational outreach, EHR modifications, and the pharmacist-facing electronic alert each contributed substantially to the overall reduction, demonstrating the additive benefits of the intervention components.
- The greatest reduction was observed in patients with stable coronary artery disease (CAD).
- In patients with stable CAD, antiplatelet use decreased by an additional 2.1 percentage points every six months compared with controls.
- This reduction in the stable CAD subgroup corresponded to a 5.5% greater decline relative to the baseline prevalence of antiplatelet use.
The researchers concluded that the stewardship initiative was associated with meaningful reductions in potentially harmful combination antithrombotic therapy. They noted that combining education, EHR-based tools, and pharmacist-directed alerts may help health systems more rapidly implement evidence-based prescribing practices and improve medication safety for patients receiving anticoagulation therapy.
Reference:
Kurlander JE, Parra D, Moore V, et al. Multilevel Stewardship Intervention for Use of Anticoagulation-Antiplatelet Therapy. JAMA Intern Med. Published online June 22, 2026. doi:10.1001/jamainternmed.2026.2036
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