Photo courtesy of NIGMS
Researchers have developed an intervention intended to help hospitals and clinicians improve the management of patients on warfarin.
The team implemented the intervention at 8 medical centers in the New England region of the Veterans Health Administration (VA).
These
centers saw an improvement in time in the therapeutic range
(TTR) that was significantly better than the improvement seen in medical
centers without the intervention.
“Insufficient attention has been given in the past to how we can improve the management of warfarin,” said Adam Rose, MD, of Boston University School of Medicine in Massachusetts.
“This study demonstrates that a relatively simple approach can have a large impact.”
Dr Rose and his colleagues described this study in the Annals of Pharmacotherapy.
Intervention
The researchers implemented the intervention at 8 VA sites in New England known as Veterans Integrated Service Network 1 (VISN 1).
The team described the intervention as performance measurement augmented by targeted audit and feedback. Performance was measured via an online reporting system—known as a dashboard—that provided real-time data to clinicians.
The dashboard reported TTR at the patient and site level. The dashboard also reported processes of care that have been linked to TTR, including timely follow-up when the international normalized ratio (INR) is very low or very high, gaps in monitoring, and the proportion of patients with a mean INR value between 2.3 and 2.7.
The dashboard allowed clinicians to call patients who had been lost to follow-up, had low TTR, or were in need of urgent follow-up as a result of extreme INR values.
Results
The researchers examined changes in anticoagulation control, measured as TTR, after the intervention was implemented. They compared changes at VISN 1 sites with 116 other VA sites.
A total of 11,794 patients within VISN 1 and 1,248,782 patients outside of VISN 1 received warfarin for at least part of the study period.
At VISN 1 sites, TTR improved from 66.4% to 69.2%. At the other sites, TTR improved from 65.9% to 66.4% (P<0.001 for the between-group difference).
The researchers said improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites.
“Patients who used these measures did better clinically than those in the control group,” Dr Rose said. “This study serves as a model for how other sites and health networks could feasibly approach improving the management of warfarin in their systems.”
“If all anticoagulation clinics in the VA were to achieve this level of improvement, it would prevent 48 strokes and 68 major bleeding events each year, with a savings to the VA system of more than $4 million annually.”
