An Intervention to Reduce Antiplatelet Use without Gastroprotection in Patients Using Warfarin: The AEGIS Cluster Randomized Trial

Abstract

Background

Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding.

Objective

To evaluate the effectiveness of a multicomponent intervention—clinician notification with nurse facilitation (CNNF)—in reducing high-risk use of antiplatelet medications in patients taking warfarin without a proton pump inhibitor (PPI).

Methods

For patients in the CNNF group, nurses sent electronic messages to clinicians identifying patients with high-risk antiplatelet use, recommending consideration of either antiplatelet discontinuation or PPI initiation, and offering to facilitate any medication changes. The primary outcome was the percentage of patients who self-reported either discontinuing antiplatelet therapy or initiating a PPI at 7 to 10 weeks. The secondary outcome was the percentage of patients with a documented clinician recommendation to make such a medication change.

Results

Among 220 patients, CNNF was associated with increased odds of discontinuing antiplatelet therapy or initiating a PPI in the intention-to-treat analysis (adjusted odds ratio [aOR] 5.76, 95% CI 2.54, 13.05). The effect was stronger in a modified completer analysis (n = 126, aOR 43.6, 95% CI 6.56, 289.88). The intervention was also associated with increased odds of a clinician recommendation for a medication change (75/110 [68.2%] versus 1/110 [0.9%], log aOR 19.86, 95% CI 10.63, 29.09). Surgeons and proceduralists were less likely to recommend medication changes relative to other clinicians (log aOR −16.08, 95% CI −23.34, −8.82).

Conclusion

The multicomponent intervention effectively led to antiplatelet discontinuation or PPI initiation in patients initially prescribed warfarin-antiplatelet therapy without gastroprotection.

Keywords

gastrointestinal hemorrhage - anticoagulants - warfarin

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