Antithrombotic Stewardship: Overcoming Barriers to System-Level Change

Securing executive buy-in, building multidisciplinary coalitions, and targeting inappropriate antiplatelet use are among the most critical — and most challenging — steps in implementing antithrombotic stewardship programs, according to Darren Triller, PharmD. In this interview, Triller outlines the common barriers health systems face, offers a roadmap for making the case to administrative leadership, and identifies the pharmacist-driven intervention he believes can deliver the fastest and most impactful results for patients on anticoagulants.

Q: You discussed antithrombotic stewardship as a more holistic, population-level approach modeled after antimicrobial stewardship, which we're very familiar with. In your experience, which core elements are the hardest for organizations to implement, and what are the common barriers they run into?

Darren Triller, PharmD: The hardest one really is executive or administrative support. As we touched on earlier, it's wonderful if individual clinicians are caring and trying to do the right things—and in many cases, they are for the populations of patients they manage. Let's say you are at an anticoagulation clinic in a large health system: the people are referred to you, and you manage those 20, 30, or 50 patients. But you really need executive leadership to say, "Care is better that way.” We need to do it for everyone. We need to build the dashboard, or we need to license one. We need to resource a pilot or scale it. So administrative support is the hardest element—and not to bash on executives, which is so fun and easy to do, but they're looking at a whole health system, a whole population, and quality measures that are tied to money, whether it's Medicare or other things. They have competing interests they have to weigh. So when the pharmacy comes forward and says, "We'd like to do this," it may make perfect sense to the pharmacy, but it has to make perfect sense in the context of everything else the executive is facing. You really have to think about this: what is the value statement we're going to make? What is the business plan? Because if you don't do those things, you're just noise—and as well thought out and as important as it is, and as fired up as you might be about it, unless you've really thought it out that way, you're going to have a hard time getting it through.

The good news is we have a lot of data now — published papers and other things from the VA and from large academic medical centers — where it's much easier to make those convincing arguments. I did send you a link to a manuscript that Dr. Jory May and others from the AC Forum put together on exactly this topic: How do you engage executive leaders? I think that paper is applicable to any care setting, and it very much follows the lines of getting a multidisciplinary team together. Pharmacy is great, but pharmacy really needs to work with medicine, nursing, lab, and others—especially if it's going to be impactful and well accepted and not shot down when you get far enough along. If you did this entirely within the echo chamber of pharmacy and then brought it forward, all it takes is someone from another discipline to say, "Who does pharmacy think they are?" and then it's done.

So get a multidisciplinary group together. Look at multiple priority areas that you think are important, and be very thoughtful about where the impact is. What has the lower hurdle to prove that it works, or the lower investment to get your foot in the door? Because once it starts rolling, people realize it makes sense, and they'll give you more—but the first one is really, really important. Follow the structure for building out a business plan, gather the evidence, and so on. That manuscript by Jory May et al. has a lot of those details and key references. It cites an American College of Clinical Pharmacy (ACCP) framework for pharmacists building business plans. We think we have a pretty good roadmap there.

So, executive leadership, follow the path, and I can't argue strongly enough to really bounce ideas off people outside pharmacy. Go to the quality department, go to the chief financial officer (CFO), ask them what their pain points are, and try to solve the system's problems — not just something you feel strongly about — because you'll learn, you'll modify, and then you'll have colleagues who help you move it forward. Long answer to a short question, but I think it's the executive leadership, and I think we have a roadmap for helping people get there.

Q: Anticoagulants now account for more than 20% of outpatient adverse drug events and are trending upward compared with antibiotics and opioids. What specific pharmacist-driven interventions have shown the greatest impact in bending that curve toward safer use?

Triller: It's a striking statistic, but 5 of the top 7 drugs contributing to emergency room (ER) visits for adverse drug events among people 65 and older in the U.S. are antiplatelet drugs and anticoagulants, and the combination has been shown to be quite harmful and not helpful. There are more ER visits due to anticoagulants and antithrombotics than opioids, and no one calls it an antithrombotic epidemic. These are all important points, but I just want to put it in that context.

Antiplatelet use — typically aspirin — in conjunction with anticoagulants is a remarkably dangerous combination. There are use cases for it: if you just had a myocardial infarction (MI) or a vascular procedure, there are often regimens that use those in combination. But the evidence is mounting in each of those specialty areas that the duration of that overlap needs to be shorter and shorter. Primary prevention use of aspirin—like, "I just take an aspirin a day"—was drilled into our heads for decades, and the older generation can adhere to that. But inappropriate antiplatelet use is probably the easiest, most rapid, and most impactful system-level change in this anticoagulation population that pharmacists can make. If you look at Centers for Disease Control and Prevention (CDC) data—and I gave you a link to 1 of those papers that you can share—I think 25% of adverse drug events involving anticoagulants involve the combination of antiplatelets and anticoagulants, and in most cases nowadays, it's inappropriate. The combination increases bleeding risk without adding any benefit. So taking something away as an intervention — especially when it prevents bleeding events — is a great way to go.

The other thing that makes it interesting for pharmacists is that aspirin, in many care settings, is a black hole from a data perspective. Patients can get it over the counter; it can be in combination products for headaches and other things. In the nursing home setting, depending on how things are ordered, it might be administered from stock and not dispensed individually. So if you're only looking at pharmacy dispensing data, it might not appear. Pharmacists are in a really neat position because they have more encounters with patients than almost anyone else to systematically ask about aspirin use and then have a process in place to reach out to whoever is prescribing either the aspirin, the anticoagulant, or both, and intervene.

The MiCQI program has done a lot of this. I think they started out with a fax sent to prescribers asking, "Would you like to stop it?" And then I think the medical team behind the program got to the point of saying, "No, we're just going to stop it"—because it was so compelling and there was no justification in many cases. So I think antiplatelet deprescribing is probably the quickest, most impactful, and easiest intervention: taking something away when it's found to be unnecessary.