A Successful Performance Improvement Story

The Challenge:

Multiple studies1-2 have shown that usual care in physician offices results in only ~ 40-50% of patients anticoagulated with warfarin are "in-range" resulting in risk for thrombosis and bleeding.  Inappropriate anticoagulation can occur because the clinician is unaware or unable to implement consensus guidelines for dosing warfarin, poor education of patients regarding drug and diet interactions and patients lost to follow up.  Patient morbidity and hospital admissions are the result of suboptimal therapy.9  Multiple studies have demonstrated that well run anticoagulation clinics can improve the "in range" patients to 70-75% with decreased complications.  Anticoagulation clinics are an answer but require close coordination between the anticoagulation clinic and the patient's private practice and increased number of employees (e.g., Pharmacists, Nurses,and Secretaries).  For many health systems with tight budgets, a management system that can reproduce the value of anticoagulation clinics is needed in physicians offices.

The Solution:

Create a virtual anticoagulation clinic.  Develop a secure web based program that allows integrated health systems, individual physician offices or anticoagulation clinics to implement tracking of patients, decision support implementing consensus dosing guidelines and provide standardized reliable educational material.  If run in an office, re-engineer the office by assignment of office coordinators (nurse, office assistant or physician) to improve the communication and education of patients.  For health systems, create centralized monitoring of performance by individual practices which allows deployment of resources to implement "best practice" across a health system.

Get the patient invested in their own health! Enable on-line patient viewing of clinical flowsheets and reference material to enhance patient compliance.  If patients are on home INR monitoring, allow them to enter their own INR values while receiving decision support and then notify clinicians when logging in that their patients have entered INR values.

 

The Pilot Study:
webINR at Abington Memorial Hospital

As a collaborative effort between Physicians, Pharmacists, Nursing and Administration, Abington Physician Network implemented webINR starting in July 2002 enrolling 1323 patients from 29 Internal Medicine and Family Practices.   In the first 9 months, (495 patient years of observation) the following were attained.

The early results were obtained without patient on-line access to webINR.   To further improve performance, we are currently engaging our patients through the webINR portal and  we are studying "best practices" and any potential barriers (computer access, staffing patterns, etc.) amongst the network offices.  Admissions for anticoagulation complications and hospital days are under study.   Patient satisfaction will be reviewed.  Note that Physician and Professional Office Staff satisfaction have been measured and are in the excellent range with the program.

INR Values

(comparison pre/post implementation)

 

Complications (per 100 pt - years)

(webINR vs. an anticoagulation clinic 3)

Age  and Diagnoses

(distribution in study)

Diagnoses

Intensity

Count

%

Atrial Fibrillation

Standard

656

49.6%

Venous Thromboembolic Disease (PE, DVT)

Standard

217

16.4%

Cerebrovascular Disease (CVA, TIA)

Standard

116

8.8%

Prophylaxis - S/P Hip Fx or THR Surgery

Standard

80

6.0%

Prosthetic Heart Valve - Mechanical

High

63

4.8%

Cardiomyopathy (Restrictive & Congestive)

Standard

50

3.8%

Coronary Artery Disease (s/p MI)

Standard

46

3.5%

Prophylaxis - S/P Total Knee Replacement

Standard

34

2.6%

Peripheral Vascular Disease

Standard

22

1.7%

Hypercoagulable State - Other

Standard

20

1.5%

Hypercoagulable - Antiphospholipid Syndrome

High

8

0.6%

Prosthetic Heart Valve - Bioprosthetic (12 Wks Treatment)

Standard

6

0.5%

Pulmonary Hypertension

Standard

3

0.2%

Carotid Disection

Standard

2

0.2%

TOTAL PATIENTS

 

1323

100.0%

 

 


Morbidity & Mortality Data

 

          Complications
Source Method Patients Patient-Years Data Yrs Minor Major Fatal Total
webINR - APN VAC 1323 495 2002-2003 4.03 0.60 0.20 4.63
Palaretti3 AC 2745 ~5500 mid 1990s 6.20 1.10 0.25 7.60
Landerfeld4 UC 565 876 1977-1983   7.40 1.10  
Gitter5 UC 261 221 1987-1989   8.10 0.45  
Beyth6 UC 264 440 1986-1993   5.00 0.68  
Wilt7

 

UC 44 28 1983-1993   17.8 42.8 60.6
AC 68 60 1983-1993   0.0 0.0 0.0
Chiquette8

 

UC 142 102 1991-1992   3.9 0.9 15.7
AC 176 123 1992-1994   1.6 0.0 4.9

 

 

References

  1. Ansel et al., Managing Oral Anticoagulation Therapy; Chest 2001; 119:22s-38s

  2. Gottlieb et al., Anticoagulation in  atrial fibrillation: does efficacy inclinical trials translate into effectiveness in practice?; Arch Int Med. 1994; 154:1945-1953.

  3. Palareti G, Leali N, Coccheri S et al.  Bleeding complications of oral anticoagulant treatment:  an inception-cohort, prospective collaborative study (ISCOAT).  Italian Study on Complications of Oral Anticoagulant Therapy.  Lancet 1996 Aug 17; 348 (9025):  423-8.

  4. Landefeld CS, Goldman L.Am J Med., Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy.,  1989 Aug;87(2):144-52. 

  5. Gitter MJ, Jaeger TM, Petterson TM, Gersh BJ, Silverstein MD., Bleeding and thromboembolism during anticoagulant therapy: a population-based study in Rochester, Minnesota. Mayo Clin Proc. 1995 Aug;70(8):725-33. 

  6. Beyth RJ, Quinn LM, Landefeld CS., Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin., Am J Med. 1998 Aug;105(2):91-9. 

  7. Wilt VM, Gums JG, Ahmed OI, Moore LM., Pharmacotherapy., Outcome analysis of a pharmacist-managed anticoagulation service., 1995 Nov-Dec;15(6):732-9.

  8. Chiquette E, Amato MG, Bussey HI., Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs., Arch Intern Med. 1998 Aug 10-24;158(15):1641-7

  9. McDonnell PJ, Jacobs MR., Hospital admissions resulting from preventable adverse drug reactions., Ann Pharmacother. 2002 Sep;36(9):1331-6.

     

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