Inpatient prescribing of dual antiplatelet therapy according to the guidelines: a prospective intervention study

Abstract

Background: In dual antiplatelet therapy (DAPT), low-dose acetylsalicylic acid is combined with a P2Y12 inhibitor. However, combining antithrombotic agents increases the risk of bleeding. Guidelines on DAPT recommend using this combination for a limited period of between three weeks and 30 months. This implies the risk of DAPT being erroneously continued after the intended stop date.
 Objective: The primary objective of this study is to assess the proportion of hospitalized patients treated with DAPT whose treatment deviated erroneously and unintentionally from the guidelines. We also assessed risk factors and the effect of a pharmacist intervention.
 Methods: All patients admitted to the Spaarne Gasthuis (Haarlem/ Hoofddorp, the Netherlands) who used DAPT between March 25th, 2019, and June 14th, 2019, were, in addition to receiving regular care, reviewed to assess whether their therapy was in line with the guidelines’ recommendation and whether deviations were unintended and erroneous. In the event of an unintended deviation, the pharmacist intervened by contacting the prescriber by phone and giving advice to adjust the antithrombotic therapy in line with the guideline.
 Results: We included 411 patients, of whom 21 patients (5.1%) had a treatment that deviated from the guidelines. For 11 patients (2.7%), the deviation was unintended and erroneous. The major risk factor for erroneous deviation was the use of DAPT before hospital admission (OR 18.7; 95%CI 4.79–72.7). In patients who used DAPT before admission, 18 out of 58 (31.0%) had a deviation from the guidelines of whom 8 (13.8%) were erroneous. For these eight patients, the pharmacist contacted the prescriber, and in these cases the therapy was adjusted in line with the guidelines.
 Conclusions: Adherence to the guidelines recommending DAPT was high within the hospital. However, patients who used DAPT before hospital admission had a higher risk of erroneous prescription of DAPT. Intervention by a pharmacist increased adherence to guidelines and may reduce the number of preventable bleeding cases.

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

“…Median underuse in perioperative bridging across the five studies was 25.0% (IQR 13.1 – 32.0%). While no time trend was visually apparent, underuse estimates from five retrospective chart reviews [ 22 25 26 30 32 ] and four cohort studies [ 34 36 38 39 ] since 2020 in Europe and North America have remained below 33% (9–32%) by comparison with 36%–72% reported between 2015 and 2019, but we did not formally test this.…”

“…Study designs included 14 retrospective record reviews [ 20 21 22 23 24 25 26 27 28 29 30 31 32 33 ], 6 cohort studies [ 34 35 36 37 38 39 ] and 1 a case-control [ 40 ] (see Table 1 ). Four studies focused on overuse, 5on underuse, and 12 on both.…”

“…Large variation in the rates of antithrombotic overuse was observed across geographic regions with studies from Asia reporting the lowest levels of overuse (1.3–7.6%) [ 27 33 ], followed by Australia (24.1–42.9%) [ 20 23 24 ], and Europe (1.4–72.0%) [ 21 25 28 29 30 33 36 37 38 39 40 ], through to the highest variation in North America (6.6–73.0%) [ 26 31 32 34 35 ]. No clear time trend of increasing or decreasing overuse was observed over the period of the studies (2008–2020).…”

“…• Integration of pharmacists in post-discharge follow-up to cease time-limited medication when no longer indicated [38] • Training of and alerts for high-volume prescribers [44] • Decision support tools [45] • Public awareness campaigns [4] • Health literacy programs on overdiagnosis to reduce healthcare expectations [46] To reduce underuse…”

Quality of acute ischemic stroke care at a tertiary Hospital in Ghana

“…This wide gap between this guidelines-directed recommendation and clinical practice at the TTH presents an opportunity for ischemic stroke care improvement through continuous professional development programs aimed at physicians and clinical pharmacists involved in the patient care process. Interventions instituted by pharmacists can increase adherence to guidelines recommendations on the need to prescribe antiplatelets to patients who have indications for it, including ischemic stroke patients with no contraindication [ 36 ].…”