Measuring quality of oral anticoagulation care: extending quality measurement to a new field.

BACKGROUND: Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care. LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION: Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care.
CONCLUSION: Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.