Metric for recommending low-dose aspirin prophylaxis

Metric for recommending low-dose aspirin prophylaxis | Image Credit: © fizkes - © fizkes - stock.adobe.com.

Low-dose aspirin prophylaxis is underutilized in individuals with increased risk of preeclampsia, leading a metric for risk factors and improvements to be developed and published in The American Journal of Obstetrics and Gynecology.

Maternal death, severe maternal morbidity, preterm birth, and perinatal death are often caused by hypertensive disorders, which are seen in 13% to 16% of pregnancies. About 4% of pregnancies are impacted by preeclampsia, which has seen a rising rate since 1980.

Risks of preeclampsia and associated complications can be reduced by prophylactic low-dose aspirin, with a daily dose of prophylactic low-dose aspirin in patients with a high-risk factor or more than 1 moderate-risk factor recommended by the US Preventive Services Task Force, American College of Obstetricians & Gynecologists, and Society for Maternal-Fetal Medicine.

Despite the benefits of prophylactic low-dose aspirin, it is utilized in under 50% of patients with high-risk factors and under 25% of patients with moderate risk factors. Potential low rates of recommendation from providers, patients not remembering they received a recommendation, and patients being hesitant to take the medicine despite recommendations are all factors attributed to low rates of use.

Investigators created a process metric to examine performance at baseline and follow improvements, evaluating patients with prophylactic low-dose aspirin incidence at 16 weeks’ gestation. The metric was designed as a tool to use locally so resources may be available to different providers and facilities.

Patients with an indication for aspirin prophylaxis and a visit to the responsible provider were used as the denominator of the metric. The definition of a visit can vary based on the individuals performing the assessment. 

The level of evidence to determine aspirin prophylaxis initiation, which is used to define a patient in the numerator, may also vary. The preferred numerator only includes patients who consistently take low-dose aspirin throughout pregnancy. Aspirin initiation before week 16 of gestation is required to be in the numerator.

The suggested optimal dosage of aspirin is 100 mg to 150 mg. However, the dosage needed to qualify for the numerator may vary between project teams. While the metric may be applied to general populations, investigators recommended stratification by race, ethnicity, language, income level, and other social determinants.

To improve the rate of prophylactic aspirin use in patients with risk factors, the metric included relatively simple processes which may lead to improvements. One of these is to study the baseline for understanding why a quality gap exists. The metric recommends a chart review of a small sample of patients.

The metric also recommends assembling a team. Team cohesiveness will often lead to improved performance and preferred patient outcomes. Setting aims is also recommended, which should be Specific, Measurable, Action-Oriented, Realistic, Time-bound, Inclusive, and Equitable (SMARTIE). The initial target should be realistic to ensure it can be reached.

Project teams will need to make choices on how the rate will be calculated, such as which patients to track, what to include in the denominator, aspirin dosages to include, and how prophylaxis is defined. These choices should be settled in advance for uniform calculation.

There are 3 approaches for improving performance, the first of which is to increase the rate of aspirin prophylaxis recommendations from providers, the second to improve provider-patient communication about prophylaxis, and the third to remove barriers to patient adherence with recommended prophylaxis.

Teams should also measure interventions to confirm associated improvements. If the SMARTIE aims are not reached despite improvements, adjustments to interventions should be made. Also, a system for measuring performance occasionally should be implemented after aims are met.

This metric may be used for improving rates of low-dose aspirin prophylaxis. This is a more cost-effect method than selective prophylaxis, and has proven efficiency, making it valuable for treating patients with risk factors for preeclampsia.

Reference

Society for Maternal-Fetal Medicine (SMFM), Combs A, Kumar N, Morgan J, SMFM Patient Safety & Quality Committee. Society for Maternal-Fetal Medicine Special Statement: Prophylactic low-dose aspirin for preeclampsia prevention – Quality metric and opportunities for quality improvement. American Journal of Obstetrics and Gynecology. 2023. doi:10.1016/j.ajog.2023.04.039