Geoffrey Barnes

• M.D., MSc.
• Professor (Associate) at University of Michigan

Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding. To evaluate the effectiveness of a multicomponent intervention—clinician notification with nurse facilitation (CNNF)—in reducing high-risk use of antiplatelet medications in patients taki...

Background Atrial fibrillation (AF) is associated with an increased risk of stroke. Oral anticoagulation (OAC) is used for stroke prevention in AF, but it also increases bleeding risk. Clinical guidelines do not definitively recommend for or against OAC for patients with borderline stroke risk. Decision-making may benefit from values clarification...

Background Home-based care for patients diagnosed in emergency departments (EDs) with low-risk pulmonary embolism (PE) is an evidence-based, guideline-recommended practice that is not widely adopted in the US. Few studies demonstrate how this care pathway can be implemented effectively or test whether implementation strategies can address known bar...

Introduction: It is unknown how comorbid diagnoses affect patients’ disease-specific knowledge or how patients’ health literacy or numeracy affects this relationship. In patients with atrial fibrillation (AF), comorbidities can be quantified by the CHA 2 DS 2 -VASc score. We explore the association of AF/stroke knowledge with CHA 2 DS 2 -VASc score...

Background: Deciding to use oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF) is complex. For many, the decision between treatment and non-treatment requires a primary tradeoff between the risks of potential stroke and increased bleeding. Hypothesis: We hypothesized that patient values and empiric stroke ris...

Purpose The initiation of specialty medications is associated with patient access challenges and clinician burden. This evaluation assessed the impact on patient and clinician experience of an intervention to improve medication access by investing resources upstream of the prescribing step. Methods The specialty pharmacy intervention was designed...

Background Studies suggest that less than 4% of patients with pulmonary embolisms (PEs) are managed in the outpatient setting. Strong evidence and multiple guidelines support the use of the Pulmonary Embolism Severity Index (PESI) for the identification of acute PE patients appropriate for outpatient management. However, calculating the PESI score...

Objective To evaluate the effectiveness of multiple decision aid strategies in promoting high quality shared decision making for prevention of stroke in patients with non-valvular atrial fibrillation. Design Cluster randomized controlled trial. Setting Six academic medical centers in the United States. Participants Patient participants were aged...

Importance Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients. Objective To identify barriers and facilitators of guideli...

Background: Guidelines recommend shared decision-making (SDM) for patients with atrial fibrillation (AF) making decisions regarding anticoagulation for stroke prevention. Decision support tools (e.g., Decision Aids [DAs]) facilitate SDM. However, little research has compared the effectiveness of the two most common types of DAs: (1) encounter decis...

Background: Despite well-known morbidity and mortality benefits, implementation of guideline-directed medical therapy (GDMT) for HFrEF patients remains suboptimal. Understanding the center-level variation in observed-to-expected GDMT prescribing could support targeted improvement initiatives. Hypothesis: The risk-adjusted observed to expected (O/E)...

Background While direct oral anticoagulants (DOACs) have improved oral anticoagulation management, inappropriate prescribing remains prevalent and leads to adverse drug events. Antithrombotic stewardship programs seek to enhance DOAC prescribing but require scalable and sustainable strategies. Objective We present a pilot, prescriber-level randomi...

Introduction: Apixaban and rivaroxaban are the most commonly used direct oral anticoagulants (DOACs) for the management of venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). For patients at clinical equipoise for continued anticoagulation after six months of standard anticoagulation treatment, proph...

Introduction: After the publication of several large, randomized clinical trials, guidelines have suggested a reduced role for primary prevention aspirin. Specifically, the 2019 American Heart Association and American College of Cardiology guidelines indicate that low dose aspirin should not be administered on a routine basis for primary prevention...

Recent guidelines have recommended a reduced role for primary prevention aspirin use, which is associated with an increased bleeding risk. This study aimed to characterize guideline-discordant aspirin use among adults in a community care setting. As part of a quality improvement initiative, patients at 1 internal medicine and 1 family medicine clin...

Pulmonary embolism (PE) is a common cardiovascular disease diagnosis in emergency departments that can be associated with significant morbidity and mortality. One of the first steps after diagnosing PE is to risk stratify for adverse outcomes using risk scores such as PE Severity Index and European Society of Cardiology risk scheme. While intermedi...

Background Direct oral anticoagulants (DOACs) have complex dosing regimens and are often incorrectly prescribed. We evaluated a nationwide DOAC population management dashboard rollout whose purpose includes pharmacist review and correction of off‐label dosing prescriptions. Methods and Results Using data from Veterans Health Affairs, we identified...

Introduction Direct oral anticoagulants (DOACs) have overtaken warfarin in the treatment of nonvalvular atrial fibrillation (AF) and venous thromboembolism (VTE). Limited data explore the safety of DOACs in obesity. Methods This multicenter retrospective study between June 2015 and September 2019 uses the Michigan Anticoagulation Quality Improveme...

Background The health consequences of polytobacco use are not well understood. We evaluated prospective associations between exclusive, dual, and polytobacco use and diagnosed bronchitis, pneumonia, or chronic cough among US youth. Methods Data came from Waves 1–5 of the Population Assessment of Tobacco and Health Study. We categorized time-varyin...

Background Venous thromboembolism (VTE) is the third leading cause of preventable hospital-associated (HA) death. Most HA-VTE, including fatal pulmonary emboli, occur among medically ill patients. The rate of symptomatic VTE more than doubles over the first 21 days after hospital discharge. Trials have demonstrated that the burden of HA-VTE may be...

BACKGROUND While direct oral anticoagulants (DOACs) have improved oral anticoagulation management, inappropriate prescribing remains prevalent and leads to adverse drug events. Antithrombotic stewardship programs seek to enhance DOAC prescribing but require scalable and sustainable strategies. OBJECTIVE We present a pilot, prescriber-level randomi...

Background While direct oral anticoagulants (DOACs) may be viewed as simpler to manage then warfarin, they present their own unique management challenges resulting in frequent off-label dosing. It is unknown to what extent off-label dosing occurs when a patient is started on a DOAC versus later in their treatment. Objectives We aimed to better char...

Background Guidelines recommend shared decision making (SDM) for anticoagulation selection in patients with atrial fibrillation (AF). Decision aids (DAs) are tools that facilitate SDM. However, the comparative effectiveness between an encounter decision aid (EDA) and a pre- encounter patient decision aid (PDA) remains unexplored. Our objective was...

Background The management of warfarin therapy presents clinical challenges due to its narrow therapeutic index. We aimed to evaluate the comparative effectiveness of different management strategies in patients using warfarin. Methods PubMed, Embase, Cochrane CENTRAL, CINAHL, and EBSCO Open Dissertation were searched from inception to 8 May 2024. R...

Background High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined. Study Hypothesis We hypothesized that different HS-TnT cutoff values may be optimal for identif...

Background For patients anticoagulated with direct oral anticoagulants (DOACs) or warfarin and on aspirin (ASA) for nonvalvular atrial fibrillation and/or venous thromboembolism, it is unclear if bleeding outcomes differ. Objectives To assess bleeding rates for ASA with DOACs vs warfarin and one another. Methods Registry-based cohort study of pat...

Background Overuse of antiplatelet therapy and underuse of gastroprotection contribute to preventable bleeding in patients taking anticoagulants. Objectives (1) Determine the feasibility of a factorial trial testing patient activation and clinician outreach to reduce gastrointestinal (GI) bleeding risk in patients prescribed warfarin–antiplatelet...

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by five times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacolog...

Anticoagulation is a leading cause of medication‐related harm. As a result, there is increasing recognition of the importance of the development of anticoagulation stewardship programs to ensure safe and effective anticoagulation use across health care settings. Securing administrative leadership support to build such programs is a necessary first...

Background: As preferences for oral anticoagulation shift from warfarin to direct oral anticoagulants (DOACs), a new care management model is needed. A population approach leveraging a DOAC Dashboard was implemented to track all patients on a DOAC followed by a physician at an academic medical center. The DOAC Dashboard is a real-time report within...

Background The health consequences of polytobacco use are still well not understand. We evaluated prospective associations between exclusive, dual, and polytobacco use and diagnosed bronchitis, pneumonia, or chronic cough among US youth. Methods Data came from Waves 1–5 of the Population Assessment of Tobacco and Health Study. We categorized time-...

Background Despite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the United States (US) healthcare system remains underutilized. Objectives To gain an understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through qualitative exploration of the opinions of select US patie...

Introduction Nonsteroidal anti-inflammatory drugs (NSAIDs), available without a prescription, are some of the most commonly used drugs in the United States. For patients on oral anticoagulation (OAC), concomitant NSAID use can increase the risk of bleeding. Patients are often advised to avoid this drug combination, or else consider adding a proton...

Introduction Apixaban and rivaroxaban are the most commonly used direct oral anticoagulants (DOACs) for atrial fibrillation (AF) and venous thromboembolism (VTE). Both have been compared to warfarin in landmark clinical trials. However, there are limited comparative efficacy data between these drugs in a real-world setting. We sought to assess pati...

During the past decade, direct oral anticoagulants (DOACs) have advanced and simplified the prevention and treatment of venous thromboembolism (VTE). However, there remains a high incidence of bleeds, which calls for agents that have a reduced risk of bleeding. Factor XI (FXI) deficiency is associated with lower rates of venous thrombosis and strok...

Background Despite direct oral anticoagulants (DOACs) being safer than warfarin for stroke prevention in atrial fibrillation (AF), major bleeding concerns persist. Most bleeding risk scores predate DOAC approval. Objectives This study aimed to compare the Age, history of Bleeding, and non-bleeding related Hospitalisation [ABH] score’s performance—...

Background Direct oral anticoagulant (DOAC) medications are frequently associated with inappropriate prescribing and adverse events. To improve the safe use of DOACs, health systems are implementing population health tools within their electronic health record (EHR). While EHR informatics tools can help increase awareness of inappropriate prescribi...

Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is un...

See the Reply by Semla, Todd .

Background Despite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the United States (US) healthcare system remains small in comparison to European countries. Objectives To gain understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through exploration of the opinions of se...

This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting r...

Rationale: Acute pulmonary embolism (PE) is a leading cause of cardiovascular death. There is limited data on the national mortality trends from PE. Understanding these trends is crucial for addressing the mortality and associated disparities associated with PE. Objectives: to analyze the national mortality trends related to acute PE and determi...

Purpose of review The goal of this review is to provide the reader with an overview of cancer-associated thromboembolism (CAT) and current therapeutic approaches to its primary prevention and initial treatment. Recent findings Given several favorable randomized trials of chemoprophylaxis for CAT, recent work has focused on patient risk stratificat...

This quality improvement study examines the accuracy of electronic health record (EHR) documentation of aspirin use for primary prevention of atherosclerotic cardiovascular disease in adult outpatients.

Background Persistent symptoms of chest pain, dyspnea, fatigue, lightheadedness, and/or syncope more than 3 months after an acute pulmonary embolism (PE) are collectively classified as postpulmonary embolism syndrome (PPES). Although PPES is increasingly recognized as an important long-term sequel of acute PE, its contemporary incidence is unclear....

Background Available resources within an organization can determine the implementation success of an intervention. However, few studies have investigated how the required resources change over the phases of implementation. Using stakeholder interviews, we examined the changes in and interactions between available resources and implementation climat...

Acute pulmonary embolism (PE) is a frequently diagnosed condition. Prediction of in-hospital deterioration is challenging with current risk models. The Calgary Acute Pulmonary Embolism (CAPE) score was recently derived to predict in-hospital adverse PE outcomes but has not yet been externally validated. Retrospective cohort study of normotensive ac...

Direct Oral Anticoagulants (DOACs) are beneficial blood-thinning medications that are frequently misprescribed. Clinical decision support systems can be effective in reducing these prescription errors through well-designed medication alerts. The effectiveness of alerts can be improved through a User Centered Design (UCD) process. We describe the mu...

Purpose: Electronic Nicotine Delivery Systems (ENDS) use among adolescents has increased greatly over the past decade, but its impact on chronic respiratory health conditions, like asthma, is not fully understood. Methods: We examined data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study using discrete time haz...

Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding...

BACKGROUND Direct oral anticoagulant (DOAC) medications are frequently associated with inappropriate prescribing and adverse events. To improve the safe use of DOACs, health systems are implementing population health tools within their electronic health record (EHR). While EHR tools can help increase awareness of inappropriate medication prescribin...

Background Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10–15% of patients receiving these medications get unsafe doses based on a patient’s kidney or liver function, potential interactions with other medic...

Background: Post-hospitalization thromboprophylaxis can reduce venous thromboembolism (VTE) risk for non-surgical patients but may carry bleeding risks. We aimed to externally validate the Intermountain Risk Scores for hospital-associated venous thromboembolism (HA-VTE IMRS) and major bleeding (HA-MB IMRS) for VTE and bleeding outcomes. Methods:...

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding...

OBJECTIVES/GOALS: Assess the association of PK-related single nucleotide variants (SNVs) with the risk of bleeding from DOACs in non-valvular AF patients. METHODS/STUDY POPULATION: A retrospective cohort study was carried out with 2,364 Caucasians with non-valvular AF and treated with rivaroxaban or apixaban. Patients were genotyped as part of the...

Objective Electronic nicotine delivery systems (ENDS) products have emerged as the most popular alternative to combustible cigarettes. However, ENDS products contain potentially dangerous toxicants and chemical compounds, and little is known about their health effects. The aim of the present study was to examine the prospective association between...

Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each f...

Introduction: Understanding the relationship between ENDS use and chronic obstructive pulmonary disease and other respiratory conditions is critical. However, most previous studies have not fully adjusted for cigarette smoking history. Methods: Using Waves 1-5 of the U.S. Population Assessment of Tobacco and Health study, the association between...

Oral anticoagulation therapy has evolved beyond vitamin K antagonists to include oral direct thrombin inhibitors and factor Xa inhibitors. Collectively known as 'direct oral anticoagulants', this class of medications represents the current standard of care for the prevention and treatment of common thrombotic disorders, including atrial fibrillatio...

Acute pulmonary embolism (PE) is associated with heterogeneous presentation from asymptomatic individuals to cardiogenic shock and acute mortality. While most patients with acute PE can be treated with anticoagulation therapy alone, some patients require more advanced interventions. Acute PE is encountered across a variety of different specialties,...

Safety and efficacy of direct oral anticoagulants (DOAC) in low weight patients with atrial fibrillation (AF) is unclear due to few low body weight patients enrolled in clinical trials. To assess bleeding and thrombotic event rates for patients with AF that are prescribed apixaban and have a low versus normal body weight. We analyzed patients with...

Billions of individuals worldwide have benefited from the unprecedented large-scale rollout of COVID-19 vaccines. Given the sheer number of people that have received these vaccines, it is not surprising that rare side effects are reported that were not previously detected in the phase III vaccine trials. This review addresses one rare complication...

Background: Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Ve...