Enhancing anticoagulation stewardship: A resident-focused quality improvement project

Abstract Background: Anticoagulation (AC) is a cornerstone in the management of hematologic and thromboembolic disorders, including venous thromboembolism (VTE), atrial fibrillation (AF), thrombophilias, prosthetic valve-associated thrombosis, and malignancy-associated thrombosis. However, extended anticoagulant use beyond evidence-based durations remains prevalent, often due to clinical inertia, limited familiarity with evolving guidelines, and overestimation of thrombotic risk. Inappropriate continuation of therapy exposes patients—particularly older adults with comorbidities—to increased bleeding risk. Guideline-based de-escalation offers a critical opportunity to reduce harm and optimize care. Despite this, few studies target resident education in anticoagulation de-escalation and combine quality improvement initiatives within ambulatory clinics. This study was a 2-pronged approach: (1) identify eligible patients that meet criteria for de-escalation as well and (2) equip internal medicine residents with the knowledge and skills to assess appropriateness of continued anticoagulation and pursue de-escalation strategies in alignment with current hematology and cardiology guidelines. Methods: Education Component: Internal medicine residents at a large academic program participated in a focused educational session covering anticoagulation management across key hematologic (e.g. VTE, AF, thrombophilias) and cardiac indications. Content was grounded in current guidelines from the American Society of Hematology (ASH), American College of Chest Physicians (CHEST), American Society of Clinical Oncology (ASCO), and American College of Cardiology (ACC). Pre- and post-intervention assessments included multiple-choice knowledge items and Likert-scale items evaluating confidence, comfort, and motivation with anticoagulation management. Statistical analysis was performed using two-tailed Student's t-tests with unequal variance. Clinical Component: Patients at the outpatient resident clinic were screened for the following criteria: adults >18 years on chronic anticoagulation (e.g., warfarin, DOACs, low-molecular-weight heparin) for AF, VTE, or hematologic thrombophilia that completed minimum therapeutic duration of anticoagulation. A resident team reviewed these patients for eligibility to be identified as “de-escalation candidates” and subsequently contacted these patients for de-escalation of anticoagulation as well as their providers. Results: Education Outcomes: Amongst 108 eligible residents, 65 completed the pre-intervention survey and 57 completed the post-intervention assessment. Mean knowledge scores showed significant improvement from 39% to 79% correct (p < 0.01). Residents also reported significantly improved confidence in multiple domains: applying guideline-based anticoagulation (mean Likert score 2.9 to 4.0), recognizing de-escalation candidates (2.8 to 4.0), and integrating this practice to routine care (4.0 to 4.5) (all p < 0.01). 98% of participants found the session engaging and reported increased motivation and comfort (96%) with initiating anticoagulation discussion. Clinical Outcomes: Of 136 patients screened in the clinic, 13 (9.5%) met criteria for possible de-escalation. Among these, 4 (33%) had already undergone de-escalation, 4 (33%) were in the process of evaluation, and 1 patient (8%) was de-escalated directly due to the intervention. The remaining candidates required additional clinical data or specialist input to guide further action. No significant differences were found in age, sex, race/ethnicity, or anticoagulation indication between patients who were de-escalation candidates and those who were not, suggesting these opportunities may be broadly applicable across patient populations. Conclusion: This resident-led project improved confidence in anticoagulation management and identifying outpatient candidates for safe de-escalation as both an education and quality improvement initiative. The findings suggest that the primary barrier to anticoagulation management may be limited awareness of evolving guidelines rather than patient complexity. Embedding anticoagulation stewardship into residency training may promote safer prescribing practices moving forward.