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Thromb Haemost
DOI: 10.1055/a-2544-6104
Coagulation and Fibrinolysis

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

Jacob E. Kurlander   *
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
2   Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States
3   Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, United States
,
Danielle Helminski   *
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Xueting Tao
5   Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, United States
,
Sameer D. Saini
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
2   Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States
3   Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, United States
,
Sarah L. Krein
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
2   Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States
3   Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, United States
,
Caroline R. Richardson
4   Department of Family Medicine, Brown University, Providence, Rhode Island, United States
,
Kelley M. Kidwell
5   Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, United States
,
Michael S.M. Lanham
6   Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, United States
7   Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, United States
8   University of Michigan Office of Clinical Informatics, Ann Arbor, Michigan, United States
,
Jennifer L. Henstock
9   Health Information Technology and Services, University of Michigan, Ann Arbor, Michigan, United States
,
Jesse Resnick
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Michael Song
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Raymond De Vries
2   Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States
6   Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, United States
10   Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Kenneth Resnicow
11   Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, United States
12   University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, United States
,
Nghi Ha
13   Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Brian Haymart
13   Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Constantina Alexandris-Souphis
13   Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
James B. Froehlich
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
13   Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
,
Geoffrey D. Barnes 
1   Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
2   Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States
13   Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
› Author Affiliations Funding This study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases through a K23 award (K23DK 118179) (JEK). Dr. Krein is supported by grant funding from the US Department of Veterans Affairs (RCS 11-222). No other funding of study authors was reported.
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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

Note

The views expressed in this manuscript do not necessarily represent the views of the United States Department of Veterans Affairs or the National Institutes of Health.


Authors' Contribution

J.E.K. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: J.E.K., D.H., S.D.S., C.R.R., S.L.K., M.S.M.L, G.B. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: J.E.K., D.H., G.B. Critical review of the manuscript for important intellectual content: All authors. Statistical analysis: J.E.K., D.H., X.T., K.M.K. Obtained funding: J.E.K. Administrative, technical, or material support: J.E.K., D.H., B.H., C.A.-S., R.d.V., K.R., J.B.F., G.B. Supervision: J.E.K., D.H., B.H., C.A.-S., J.B.F., G.B.


* These authors are co-primary Authors.


Supplementary Material



Publication History

Received: 01 October 2024

Accepted: 21 February 2025

Article published online:
02 May 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

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