A Resident-driven Initiative to Improve the Appropriate Use of Aspirin for Primary Prevention

From the 2022 HVPA National Conference

Adam Fawaz MD (Cleveland Clinic Foundation), Basel Bazerbachi MD, John Gaskill DO, Helene Puzio DO, Matthew Reeder MD, Katie Shen MD, Arsal Tharwani MD, Nivaas Thanoo MD, Jessica Donato MD


Cardiovascular disease (CVD) is the leading cause of mortality in the US. The American Heart Association (AHA) recommends the use of Aspirin for primary prevention of CVD in patients between the ages of 40-70 who are at increased risk of CVD, but not at higher risk of bleeding. We have noted that among the resident patient panel at the Cleveland Clinic, there is a significant number of patients on Aspirin for primary prevention.


The objective of this project was to identify patients in the resident panel who were inappropriately on aspirin for primary prevention, and to devise a provider driven approach to de-prescribe aspirin in the hope of increasing the percentage of patients who were on aspirin appropriately for primary prevention.


An aspirin dot phrase was introduced within the resident note in the electronic medical record. The dot phrase included risk factors which increase the risk of CVD, and the risk of bleeding. Residents identified patients on their schedule who were on aspirin for primary prevention. During the encounter, the topic of aspirin use was discussed with the patient, using the dot phrase to discern if they are on aspirin in-appropriately, in order to de-prescribe aspirin.


A total of 27 patients on aspirin for primary prevention were identified, 13 appropriate, and 14 inappropriate. Through the use of the dot phrase, we were able to de-prescribe 11 patients off of ASA. Accordingly, our percentage of patients on aspirin appropriately increased from 48.1% (13/27) to 81.25 % (13/16).


Aspirin use has been shown to decrease the incidence of CVD, and increase the risk of bleeding. Accordingly, we should follow an evidence based approach when prescribing aspirin for primary prevention. The dot phrase was successful in the de-prescription of aspirin when prescribed inappropriately. Our hope is to employ the dot phrase systematically in every patient encounter across the Cleveland Clinic health system to help identify patients who would qualify for aspirin for primary prevention, and de-prescribe aspirin to any who are inappropriately prescribed.

Clinical Implications

An intervention with minimal resource commitment may lead to significant improvement in the rates of appropriate aspirin prescription.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog