Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy

Abstract

Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration.

Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence.

Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction (P = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk.

Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.

Publikationsverlauf

Eingereicht: 19. Juli 2019

Angenommen: 14. Oktober 2019

Artikel online veröffentlicht:
25. Mai 2020

• References

• 1 Paikin JS, Eikelboom JW. Aspirin. Circulation 2012; 125: e439-e442
• 2 Alonso-Coello P, Bellmunt S, McGorrian C. et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines 2012; 141: e699S-e690S
• 3 Smith W, Lands W. Stimulation and blockade of prostaglandin biosynthesis. J Biol Chem 1971; 246: 6700
• 4 Hui AJ, Wong RM, Ching JY. et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: Analysis of 1657 cases. Gastrointest Endosc 2004; 59: 44-48
• 5 Yousfi M, Gostout CJ, Baron TH. et al. Postpolypectomy lower gastrointestinal bleeding: Potential role of aspirin. Am J Gastroenterol 2004; 99: 1785-1789
• 6 Nakajima H, Takami H, Yamagata K. et al. Aspirin effects on colonic mucosal bleeding: Implications for colonic biopsy and polypectomy. Dis Colon Rectum 1997; 40: 1484-1488
• 7 Anderson MA, Ben-Menachem T, Gan SI. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
• 8 Shiffman ML, Farrel MT, Yee YS. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDS. Gastrointest Endosc 1994; 40: 458-62
• 9 Acosta RD, Abraham NS, Chandrasekhara V. et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83: 3-16
• 10 Veitch AM, Baglin TP, Gershlick AH. et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008; 57: 1322-1329
• 11 Robbins R, Tian C, Singal A. et al. Periprocedural management of aspirin during colonoscopy: a survey of practice patterns in the United States. Gastrointest Endosc 2015; 82: 895-900
• 12 Bruno M, Marengo A, Elia C. et al. Antiplatelet and anticoagulant drugs management before gastrointestinal endoscopy: Do clinicians adhere to current guidelines?. Dig Liver Dis 2015; 47: 45-49
• 13 Siau K, Hannah JL, Hodson J. et al. Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival. Postgrad Med J 2018; 94: 137-142
• 14 Peery AF, Dellon ES, Lund J. et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143: 1179-1187.e3
• 15 Gaziano JM, Brotons C, Coppolecchia R. et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018; 3921036-1046
• 16 Mayeaux EJ, Murphy PW, Arnold C. et al. Improving patient education for patients with low literacy skills. Am Fam Physician 1996; 53: 205-211
• 17 Merle V, Marini H, Rongere J. et al. Does an information leaflet about surgical site infection (SSI) improve recollection of information and satisfaction of patients? A randomized trial in patients scheduled for digestive surgery. World J Surg 2011; 35: 1202-1211
• 18 Feuerstein JD, Tapper EB, Belkin E. et al. Multicenter study assessing physician recommendations regarding the continuation of aspirin and/or NSAIDs prior to gastrointestinal endoscopy. Dig Dis Sci 2015; 60: 3234-3241