From Quick Wins to Long-Term Infrastructure: A Pharmacist's Roadmap for Antithrombotic Stewardship

Not all antithrombotic stewardship interventions are created equal—some are ready to operationalize today, while others require multidisciplinary coordination and significant infrastructure investment. In this interview, Darren Triller, PharmD, walks through the relative ease and impact of each of the 5 ADAPT priority areas, makes the case for dashboard-driven population health management, and outlines how pharmacists can embed stewardship into routine practice—whether in ambulatory care, health systems, or payer-managed environments.

Q: Your presentation outlines numerous clinical conditions and management opportunities. Where do you see the biggest quick wins for pharmacists to really improve patient outcomes through these stewardship activities?

Darren Triller, PharmD: That's a great question. There are no quick wins—or maybe semi-quick wins, possibly. But I think adherence, going back to our earlier discussion, is the place to start because the data are already there. I know the Part D program has quality measures that are adherence-related, and health plans and others don't require, in most cases, the adherence measures for anticoagulants, such as in atrial fibrillation (AFib). But the mechanics are all in place: you know the codes for the indications, you know the codes for the drugs, you know the days' supply. So I think that's the easiest thing to operationalize for pharmacy—whether it's a managed care medication therapy management (MTM) program or any other clinic setting—because the data already exist. It's a single data stream: did they get the drug? You're not mixing in labs, patient weight, patient characteristics, or anything like that.

Aspirin is a quick win in the sense that if you establish something as simple as asking your anticoagulated patients whether they're taking aspirin and then intervening, that can have a very quick impact. It just takes a little more time and thought to set up.

Time in therapeutic range (TTR) for warfarin: There are still patients out there on warfarin, and they tend to be the more complex ones—patients on dialysis, patients with mechanical heart valves who need to stay on the drug. Unfortunately, 1 of the effects of the DOACs becoming available is that the size and number of warfarin clinics have diminished. So there are a lot of warfarin patients being managed by clinicians in the field, and the quality of care isn't as good as it would be through a standardized clinic. Now, with telemedicine, patient self-monitoring, and patient self-testing, there's really no reason warfarin patients shouldn't be better managed. So I think that's a fairly easy one, even if there are fewer patients on it now.

DOAC dosing: Those dashboards cover lots of patients, have a lot of impact, and there's a lot of data showing improved patient outcomes when patients are on the right doses. But you need lab data, patient weight, and diagnosis information. If there are commercial products available that are plug-and-play, that could make it straightforward.

Periprocedural management is probably the hardest, because it's such a mixed bag. What we're referring to are the decisions to stop or not stop an anticoagulant when a patient has an invasive procedure—and if you do stop, when do you stop, and when do you resume after the procedure? It's complex because the full range runs from hip and knee surgery, which is major and high-bleed, all the way to podiatry and dentistry. Am I stopping anticoagulants for a cleaning? So it gets more complex. That one definitely has to be multidisciplinary, because proceduralists are involved and they're doing things differently. The rollout is probably best done by working with specific groups of proceduralists. For example, with routine colonoscopies, engaging a gastrointestinal (GI) group and asking, "What are we doing here?"—because you cannot have people saying, "I just stop everything for a week," because that puts patients at risk of thrombosis. You need to make sure they restart their anticoagulant. I know there's a poster coming up at one of the thrombosis conferences that looks at whether patients reinitiate their anticoagulants after a colonoscopy, and the numbers aren't fantastic.

So if you want easy wins, adherence is plug-and-play, and aspirin is an easy clinical intervention to make, especially if you can document that the patient doesn't need it. The other areas take a little more thought to implement.

I also want to put in a plug for a tool we just created for the post-acute and long-term care environment that looks at exactly this: patients who have AFib and are on anticoagulants and aspirin or another antiplatelet drug; what information you need to collect to assess whether that combination is inappropriate; and if it is, how to make a recommendation to stop. That's a pretty easy clinical intervention, and you can share the link to our tool.

Q: Data analytics and system design are highlighted as foundational core elements. What types of dashboards, registries, or electronic health record (EHR)-based tools have proven most useful? I know you already mentioned dashboards. What else can really help with this?

Triller: If we're focusing predominantly on the outpatient setting, those population health DOAC management dashboards—and even warfarin management systems—cover 4 of the 5 ADAPT topics. There's data on all of them, and there are examples from large systems like the VA and MiCQI. We have 30 or more years of experience with warfarin management in large populations.

So the questions come down to: How do I acquire or build one? That's the perennial build-or-buy question about technology. If you've got an organization with a deep bench of Epic developers—or whatever system you're using—you might say, "This isn't rocket science; we can build these alerts and flags.” But you'd do well to focus on those 5 ADAPT areas in the outpatient setting.

The inpatient side gets really interesting because there are more things to address—like the use of unfractionated heparin for acute venous thromboembolism (VTE), which is really frowned upon these days, and pulmonary embolism response teams (PERTs) and how quickly we're treating pulmonary embolism the way we treat strokes and getting the right people to the table. But it's much more complicated on the inpatient side. We are working on some of these and are actually trying to develop a parallel set of acute care metrics — an ADAPT-like framework with a different acronym for acute care — hopefully in the next few months.

Q: Given the growing nationwide emphasis on continuous quality improvement, how can pharmacists integrate stewardship metrics into routine practice, whether in ambulatory health systems or payer-managed environments?

Triller: I think it's really about elevating this population of high-risk drugs and high-risk patients into the mainstream of what we're already doing. I did work for a period of time in quality at a managed care plan, where we were focusing on the measures tied to Star Ratings and tied to payment—which is great, because those have to get done. But I think simply bringing antithrombotics and anticoagulants into those conversations and that space is the starting point. Now, granted, there may not be a Star measure on this yet, but can we afford to have this class of drugs causing ER visits if we also bear the financial risk for adverse outcomes?

So I think elevating the conversation is step 1. Our goal, ultimately, would be to have required measures and required stewardship programs. But in the meantime, there are real opportunities for innovative pharmacists and pharmacy systems that are in value-based arrangements, because there is a lot of low-hanging fruit. There are roadmaps for this. If no one is doing it yet, the innovators in the pharmacy world should be able to show that an adherence program improved outcomes X, Y, Z; that a dosing program improved outcomes; and that a system is in place. It's going to be the innovators who build those things—but it's not from scratch. There's enough evidence and enough academic centers, and the VA has led the way, so it shouldn't be that hard.

Q: Is there anything you want to add or anything I didn't think to ask about?

Triller: The Anticoagulation Forum (AC Forum) is multidisciplinary by design and is a nonprofit. We've been around for about 35 years, starting as a forum for frontline clinicians in warfarin management clinics, and we've grown into all the different care settings. We do not charge membership dues. So if people are intrigued or interested, they can join our organization at no charge. We have approximately monthly webinars on these topics, newsletters, a resource center on our website, and more. There's a very low bar to getting up to speed and engaged in this space.

The other thing is that a couple of years ago, we petitioned the American Society of Health-System Pharmacists (ASHP), together with Brigham and Women's Hospital in Boston, to create a new specialty residency in thrombosis and hemostasis management. We now have 10 or 11 sites in the U.S. and a new one starting in Beirut, Lebanon. There are now around 30 or so graduates of those programs, and—as we're in May 2026—a group of about 10 is now emerging from the residency program.

Another way to approach this at the system level is to bring in someone with that expertise, either from 1 of these residency programs or by directing postgraduate year 1 (PGY1) candidates into them, if your health system wants to build that expertise. 1 of the unique things about this residency program is that it's not just clinical—there’s also a stewardship requirement built into the ASHP curriculum. These residents round through the ER, critical care, neurology, and ambulatory care, so they're going through all those care settings, but they're also working with quality improvement (QI) and pharmacy and therapeutics (P&T) committees on stewardship. That's a really well-trained cohort of pharmacists to tap into. So, join the AC Forum and look into those residents, because I think you'd do well to accelerate your programs by having those folks involved.