A qualitative evaluation of barriers and facilitators to a large-scale antithrombotic stewardship intervention in the United States Veterans Healthcare system

TL;DR

This study explores what helped or hindered a large-scale effort to safely reduce anticoagulant-antiplatelet drug use in U.S. veterans' healthcare.

Contribution

Identifies key implementation barriers and facilitators for antithrombotic stewardship in a real-world healthcare system.

Findings

Pharmacists faced challenges coordinating with specialists and educating clinicians about deprescribing benefits.

Adding a visual alert to a dashboard was seen as a helpful tool for identifying patients for deprescribing.

Adaptability to local needs and clarification of performance expectations were critical for successful implementation.

Abstract

The combined use of antiplatelet medications with direct oral anticoagulants increases patients’ risk of hemorrhage. In 2021, a multistate network of Veterans Affairs medical centers in the United States deployed a successful multicomponent stewardship initiative to reduce inappropriate anticoagulant-antiplatelet therapy.

Identify barriers, facilitators, and potential adaptations of the initiative to guide broader dissemination.

Clinical pharmacists and pharmacist managers were invited to participate in semi-structured interviews about their experiences with the initiative. Interviews were transcribed. Thematic analysis was informed by the Consolidated Framework for Implementation Research (CFIR).

Fifteen interviews were completed (response rate 68%). The initiative was considered important and worth disseminating, and the addition of a visual alert to flag potential deprescribing candidates on an anticoagulation population management dashboard was considered especially beneficial. Three primary themes were identified using the CFIR. First, pharmacists often encountered barriers to coordination across specialties, with some clinicians unconvinced of the clinical evidence favoring antiplatelet deprescribing; breaking down these clinical silos, through targeted education and identifying meaningful clinician champions, is essential to increasing success of this initiative. Second, pharmacists sought clarification about how their deprescribing efforts, a relatively new activity, would be accounted for in performance evaluations, and how clinics would meet increased staffing needs. Third, adaptability of the initiative to local context was considered valuable.

As part of a multicomponent oral anticoagulant-antiplatelet stewardship initiative, preventing clinical silos, clarifying expectations around performance and staffing, and permitting adaptations to local context are important to maximizing impact.

The online version contains supplementary material available at 10.1007/s11096-025-01922-2.