A multicenter aspirin deprescribing intervention substantially reduced excess aspirin use amid sufferers addressed with warfarin for atrial fibrillation (AF) and/or venous thromboembolism (VTE) who had no obvious sign for concomitant antithrombotic therapy.
The “deimplementation” program was related with a almost 50% decrease in over-all aspirin use throughout 6 anticoagulation clinics which in change was connected to substantially less bleeding gatherings and a minimize in wellness care use, without an maximize in thrombotic results.
Analyze authors, led by Geoffrey D. Barnes, MD, MSc, assistant professor, cardiovascular medicine and vascular drugs, College of Michigan Health and fitness System, compose that aspirin is appropriately blended with warfarin for some individuals with AF or VTE just after acute coronary syndromes or percutaneous coronary interventions, and also for some patients with mechanical coronary heart valves.
For most other sufferers, even so, the evidence suggests larger damage than good from the blend which raises the threat for bleeding occasions with out a clear reduction in thrombotic results, the authors include. Scientific tips suggest from the practice, but the investigators notice that “many individuals appear to be obtaining aspirin even when the opportunity threat exceeds the advantage.”
For most other patients, even so, the proof implies higher harm than superior from the mix of aspirin and warfarin which increases the possibility for bleeding situations without having a distinct reduction in thrombotic outcomes.
Barnes et al made use of affected individual populations attending 6 medical internet sites in the Michigan Anticoagulation Good quality Enhancement Initiative (MAQI) for the pre-submit observational high-quality advancement review, evaluating the pre- and postintervention proportion of sufferers whose aspirin use appeared unclear as perfectly as the affect of the intervention on medical outcomes.
Each and every of the 6 MAQI clinics employed a web page-specific screening course of action to establish people acquiring aspirin without a crystal clear indicator, accumulating knowledge between January 2010 and December 2019. The top quality advancement interventions took area involving Oct 2017 and June 2018, in accordance to the study.
For these clients whose indication for aspirin was unclear or appeared inappropriate, consultation with the patient’s main treatment clinician or specialist could set off discontinuation.
The indications for aspirin use had been assessed at enrollment for the pre-intervention cohort and assessed at enrollment or the first comply with-up right after implementation of the intervention for the article-intervention cohort.
The MAQI followed 6738 individuals discovered as remaining taken care of with warfarin without having an indication for aspirin (necessarily mean age, 62.8 many years 46.9% males) for a median of 6.7 months. A lot more than fifty percent (55.1%) were being receiving anticoagulation for VTE.
Overall, there was a almost 50% reduction in excessive aspirin use after the deprescribing intervention, from a 29.4% to 15.7%.
Specially, knowledge reported by Barnes and colleagues present a slight lower in use of aspirin throughout MAQI sites from a baseline indicate of 29.4% (95% CI, 28.9% – 29.9%) to 27.1% (95% CI, 26.1% – 28.%) for the duration of the 24-thirty day period preintervention period (P < .001 for slope before and after 24 months before the intervention).
Following the intervention, the decrease in aspirin use accelerated significantly to a mean of 15.7% (95% CI, 14.8% – 16.5%), a trajectory the authors point out was steeper than that seen during the preintervention period (P = .001 for slope before and after intervention).
Overall, there was a nearly 50% reduction in excess aspirin use after the deprescribing intervention, from 29.4% to 15.7%.
Results of primary analysis demonstrated a significant decrease in major bleeding events per month (preintervention, 0.31% 95% CI, 0.27%-0.34% postintervention, 0.21% 95% CI, 0.14%-0.28% P = .03 for difference in slope before and after intervention). Notably, there was no significant change from before to after the intervention in mean percentage of patients with a thrombotic event (0.21% vs 0.24% P = .34 for difference in slope).
In the secondary analysis, the research team found that reduced use of aspirin (starting 24 months prior to deprescribing intervention) was associated with decreases in mean percentage of patients:
- having any bleeding event (2.3% vs 1.5% P = .02 for change in slope before and after 24 months before the intervention)
- having a major bleeding event (0.31% vs 0.25% P = .001 for change in slope before and after 24 months before the intervention)
- with an emergency department visit for bleeding (0.99% vs 0.67% P = .04 for change in slope before and after 24 months before the intervention)
“Our findings highlight the need for greater aspirin stewardship among patients receiving warfarin for anticoagulation,” wrote Barnes and colleagues, adding that the “successful intervention across multiple health systems, with different patient populations and clinical structures, could serve as a national model for reducing excess aspirin use.”
“Given that aspirin is not a prescription medication, it could be postulated that clinicians may not always be aware that patients are taking aspirin, which is a barrier to aspirin-deprescribing efforts,” they add.
They call for additional research to determine whether deprescribing aspirin for patients receiving newer direct oral anticoagulants is similarly effective as well as to confirm the current findings, “ideally with a control group.”
Reference: Schaefer JK, Errickson J, Gu X, et al. Assessment of an intervention to reduce aspirin prescribing for patients receiving warfarin for anticoagulation. JAMA Netw Open. 20225(9):e2231973. doi:10.1001/jamanetworkopen.2022.31973