Podcast: Jacob Kurlander on Anticoagulation-Antiplatelet Therapy Stewardship Intervention

Intro: From the JAMA Network, this is JAMA Internal Medicine Author Interviews. Conversations with authors exploring the latest clinical research, reviews, and opinions featured in JAMA Internal Medicine.

Richman: Hello and welcome to our listeners around the world. You're listening to JAMA Internal Medicine author interviews. Thanks for joining us. I'm Dr. Ilana Richman, an assistant editor and web editor at JAMA Internal Medicine, and I'm joined today by Dr. Jacob Kurlander, who's a research scientist at the VA Ann Arbor Center for Clinical Management. and a staff gastroenterologist at the University of Michigan, and by Dr Seth Landefeld, a general internist and geriatrician and professor emeritus at the University of Alabama at Birmingham. Welcome to you both.

Kurlander: Thank you.

Landefeld: It's a pleasure to be here.

Richman: So in this week's issue of JAMA IM, we feature a study by Dr. Kurlander and colleagues that evaluates a deprescribing intervention for antiplatelet therapies. So, for context, many patients with coronary artery disease end up on both an antiplatelet and an anticoagulant for a number of reasons. So, say, for example, a patient with coronary artery disease has a percutaneous coronary intervention and ends up on an antiplatelet therapy, and then later develops atrial fibrillation, those patients frequently may be on both an antiplatelet and full anticoagulation. But over the last number of years, we've had this accumulating body of evidence that being on both of those medications for patients with stable coronary artery disease is not necessary and may in fact be harmful. So the focus of this study was actually to test an intervention, a multi-component intervention, to try to get patients off the antiplatelet agent. when appropriate. So to begin, I want to start with Jacob. Can you tell us a little bit about how your team conceived of this intervention? Like how did you get interested in tackling this particular deprescribing target? And how did you think about which intervention components to focus on?

Kurlander: Yeah, thanks for the question. So I should say that my team came in after the intervention actually took place to evaluate it, but I think I can speak a bit for the pharmacists who really developed this and rolled it out. So in the VA health system, many medical centers use what's called the DOAC dashboard, the direct oral anticoagulant dashboard. Proactively allows monitoring for the appropriate indication for each drug, things like appropriate renal dosing. And there's been interest in expanding the limits of what they're calling an antithrombotic stewardship approach. And as there's been this accumulating body of evidence that combination anti-thrombotic therapy, by which I mean used for both an anti-platelet drug and an anticoagulant, I think a growing body of evidence that this is actually probably harmful for the majority of patients who are prescribed the combination. And so they were thinking a lot about ways to push the boundary. And so they formed an anticoagulation workgroup within their VISN, which is a regional network of VA medical centers, in this case, seven medical centers to come up with an implementation approach.

Richman: And it was a little bit of a complex intervention. So can you just describe like the different pieces? There were two phases and just tell us a little bit about what the team actually did.

Kurlander: Sure. So in the first stage, the main piece of it was academic detailing. So these were education, outreach and coaching visits that a pharmacist did with other pharmacists and with clinicians. to help them understand the most up-to-date evidence, barriers they might be personally experiencing in de-implementing antiplatelet drugs and some approaches they might use to overcome those barriers. They also made some changes in the electronic health record. So pharmacists in the VA often approve requests for direct oral anticoagulants and then put notes in the chart. And so what they did was they put templated notes in there so that anti-platelet appropriateness was systematically addressed. At the same time, in the request forms for direct oral anticoagulants, the requesting providers also had to indicate on their end the appropriateness of anticoagulant drugs. And then finally, they had some templated letters that they could send to community care providers, so doctors outside of the VA health system, who might have additional information about the appropriateness of antiplatelet drugs. To get feedback. And similarly, they sent letters to patients like that.

Richman: This was, I think, in the paper, we also corresponded about this: that this was an enormous effort to like pound the pavement and get out there and get the word out. Can you speak to kind of like the elbow grease that goes into this kind of work?

Kurlander: Yeah, absolutely. So one of the leaders of this anticoagulation workgroup, David Parra, personally delivered more than 100 of these visits. They were small group visits. They were large groups. And I think it's really a labor of love and care for veterans to make sure that they're getting the highest quality care. This is one of the best aspects of VA care being able to undertake systematically these types of interventions. And the second part of the intervention, which I didn't mention yet, was turning on an electronic flag. In an electronic dashboard that's available throughout the VA health system. This dashboard is used to monitor safety signals in patients who are prescribed DOACs. And in this one regional network of VA medical centers, they created and turned on a flag to identify patients who were using an anti-platelet drug in addition to their DOAC.

Richman: All right. So tell us what you found. Walk us through the main results.

Kurlander: Yes. So our main question was what the effect of these interventions were in combination and each individually, what effect they had on the overall rate of antiplatelet use in these patients on DOAC. And so what we found was that the combined interventions accelerated the rate of antiplatelet de-implementation relative to control sites consisting of 128 medical centers in the rest of VA. So the combined intervention worked. It sped up the pace of the implementation. And when we broke it down by the first and the second phases of these interventions, It looked like about half and half were attributable to each of these stages.

Richman: Thank you. So I want to bring in Dr. Landefeld into the conversation. So, Seth. Tell us a little bit about the landscaping of deprescribing and how this intervention advances our understanding of what works and help us sort of situate the results in the literature.

Landefeld: Sure. Deprescribing has become increasingly important because, as in this situation, the indications for using certain drugs has evolved over time. And also, people get started on drugs many years ago that may be increasingly dangerous now. Initial efforts at deprescribing really focused on smaller practice-based interventions. And one of the things that's really unique about what Jacob has done here is this effort that touched tens of thousands of patients in a health care system that could be relatively easily extended across the rest of the VA. Another thing that has really been, I think, very potent and interesting in this intervention is the multi-component dimension of it, bringing in academic detailing, improving the knowledge base and practice of individual clinicians, physicians and advanced practice providers, also trying to improve the knowledge base of patients, since in this case, many of the drugs, the aspirin, is often taken over the counter. And then also this clinical pharmacy component is really, I think, a very potent part of this intervention where the pharmacists themselves are actively engaged on a system level. in managing prescription. So they're very well positioned to do deprescribing to eliminate the use of drugs that we now know are toxic.

Richman: I think it's one of the ways in which the VA is really extraordinary is that systems-based practice. And I'm wondering what lessons we can learn from this that might apply to other health systems that are not as coordinated or integrated. Which elements, I guess this is a question for both of you, may be most easily adopted by other institutions and which might be harder?

Kurlander: Yes. I mean, I think one broad based lesson is the role of antithrombotic stewardship, and this is catching on outside of the VA as well. But the idea that these are really risky medications, and we have really high-quality evidence now that the combination of antiplatelet and anticoagulant medications is not only increases the risk of GI bleeding. But in some of these studies, actually increases the risk of all-cause mortality, that that signal is strong enough that we should be investing in proactively making sure that we're doing everything we can to protect these patients. That would be one broad lesson. Another is in the role of multidisciplinary care. So you'll see on our paper, there's cardiologists, there's me as the gastroenterologist who's seeing these patients with GI bleeds. There's primary care providers, and there's a bunch of pharmacists. And I think none of us can do it alone. We're really working together. And that's not only in research, but clinically, we need to be conferring with each other to make the best clinical decisions for our patients.

Landefeld: Let me add, I think the potential for expanding this sort of intervention is huge. The challenges are also big. I think in the paper, Jacob and his colleagues mentioned that the VA is looking for ways to roll this out across the other 90% of the VA. That would be huge. Thinking about extending it more broadly. Probably the next biggest health system in the country is Kaiser. You know, that Kaiser would have similar potential to expand it. But then also thinking about what could large payers do, UnitedHealth or CVS Aetna. And they could be able to monitor and make implementations as well, where you can improve patient outcomes, increase safety, reduce risk and possibly reduce costs as well. Or what can large providers do like the Ascension system or atrium health systems that are providing care directly to hundreds of thousands of patients as well? I think there's huge potential for this, but making it work across all those different systems would be a real challenge. There's a lot of work to do.

Kurlander: That's absolutely right. In Michigan, Blue Cross Blue Shield has sponsored a series of quality improvement consortia to work on this issue. And so they've actually undertaken similar interventions that have worked.

Richman: One of the interesting findings from this work was also that there was considerable site heterogeneity. And I wondered if you could speak to that and if there are lessons to learn from variability across sites in your own data.

Kurlander: We certainly saw that most of the benefits were limited to a handful of the sites. And I think this is common in quality improvement initiatives, that uptake is not always universal. I think we've tried to understand why this may have been the case. And some issues that we've identified, for example, are staffing issues. Simply, if the pharmacists are not provided with time to do population health management activities, this becomes really challenging at a systems level. Another issue is siloing. So it was, I think, fairly hard for some sites to do this without being able to always engage consistently with their colleagues in other medical specialties. Those were the big ones, but I think some of these can be potentially addressed with user-centered design approaches and other techniques to hopefully reduce those barriers.

Landefeld: I think variation in the efficacy and effectiveness of interventions across site and across time is hugely important. And it's one of the big challenges for health services research is: how can we get as much consistency as practice as we get in a three-star restaurant. And this goes back as long as people have been doing health services research. You go back and look at the New York State bypass mortality data. And getting a bypass from somebody who's got a 2% mortality rate is a very different thing from getting it from somebody who has a 5% mortality rate. So trying to understand that and achieve the extraordinarily high levels of practice that some of these VA medical centers did is really important.

Richman: Identifying that secret sauce is always challenging, but I think it's one of the things that makes this work interesting and dynamic and opens up a lot of possibilities for how effective these interventions can be. All right, as a closing question, what do each of you think is like the key next question in this work? or for deprescribing in general.

Kurlander: One interesting thing we found in this study was that a lot of the deimplementation action was in the patients with coronary artery disease. And there was not as much deprescribing among patients who were on antiplatelet drugs seemingly for primary prophylaxis. And that's surprising because the patients on antiplatelets for primary prophylaxis have the most to benefit from deprescribing. They really get no benefit and all harm. And so I think we don't have a complete understanding of why that was. Some of it may have been related to a focus on these recent trials that included exclusively patients who had coronary artery disease. But I think moving forward, building into these dashboards some more clinically nuanced criteria to allow the pharmacist to select those patients who are most likely to benefit is going to make this task easier for pharmacists. And capture the low-hanging fruit when it comes to this de-implementation.

Landefeld: The first question I'd have is how can this effective intervention be extended across other health systems? The low hanging fruit there is in the VA, but then also across other providers and health systems as well. A second question is what can be done to make this intervention even more potent? It was effective, it was potent, and yet you look at the slopes of the curves and you say, gee, can't we do better than that? And 30 years ago, the VA showed that the best way to get people through vaccines is not by doing provider or patient-focused interventions, but by, you know, putting somebody at the door of VA medical center who gives everybody a jab. There are simple things like that that could be done for this.

Kurlander: Yes, and I would say that you and the VA were very fortunate to have the Office of Research and Development, and they have supported this work. They've been willing to take a magnifying glass to how it worked. And Dr. Landefeld brings up great questions about how to extend this. And I think the VA is going to be at the forefront.

Richman: So lots more to do and a lot of excitement about where this study brings us and what's to come. So thank you both for being here. This is a great conversation and delighted to be able to discuss this work.

Kurlander: Thanks very much. Thanks very much.

Richman: I'm Dr. Ilana Richman. I've been speaking with Dr. Jacob Kurlander and Dr. Seth Landefeld about antiplatelet deprescribing. You can find all the papers we discussed and more in the show notes. And on jamainternalmedicine.com. This episode was produced by Daniel Musisi at the JAMA Network. To follow this and other JAMA Network podcasts, please visit us online at jammanetworkaudio.com or search for JAMA Network wherever you get your podcasts. And thanks for listening.

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