Mark L Metersky1,2, Noel Eldridge3, Yun Wang4, Lisa Jaser1,5, Robert Bona6, Sheila Eckenrode1, Anila Bakullari1, Mary Andrawis7, David Classen8, Harlan M Krumholz9,10,11,12. 1. Qualidigm, Wethersfield, Connecticut. 2. Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, Connecticut. 3. Agency for Healthcare Research and Quality, United States Department of Health and Human Services, Rockville, Maryland. 4. Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. 5. Department of Pharmacy, Griffin Hospital, Derby, Connecticut. 6. Frank H. Netter MD School of Medicine at Quinnipiac, Hamden, Connecticut. 7. Centers for Medicare & Medicaid, United States Department of Health and Human Services, Baltimore, Maryland. 8. Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah. 9. Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. 10. Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut. 11. Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut. 12. Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
Abstract
BACKGROUND: The optimum international normalized ratio (INR) monitoring frequency for hospitalized patients receiving warfarin is unknown. OBJECTIVE: Assess relationship between daily versus less frequent INR monitoring and overanticoagulation and warfarin-related adverse events. DESIGN: Retrospective cohort study using Medicare Patient Safety Monitoring System data. SETTING: Randomly selected acute care hospitals across the United States. PATIENTS: Patients hospitalized from 2009 to 2013 for pneumonia, acute cardiac disease, or surgery who received warfarin. INTERVENTIONS: None. MEASUREMENTS: (1) Association between frequency of INR monitoring and an INR ≥6.0 or warfarin-related adverse event. (2) Association between the rate of change of the INR and a subsequent INR ≥5.0 and ≥6.0. RESULTS: Among 8529 patients who received warfarin for ≥3 days, for 1549 (18.2%) the INR was not measured on 2 or more days. These patients had higher propensity-adjusted odds ratios (ORs) of having a warfarin-associated adverse event (OR: 1.48, 95% confidence interval [CI]: 1.02-2.17) for cardiac patients and surgical patients (OR: 1.73, 95% CI: 1.20-2.48), with no significant association for pneumonia patients. Cardiac and pneumonia patients with 1 day or more without an INR measurement had higher propensity-adjusted ORs of having an INR ≥6.0 (OR: 1.61, 95% CI: 1.07-2.41 and OR: 1.92, 95% CI: 1.36-2.71, respectively). A 1-day increase in the INR of ≥0.9 occurred in 621 patients (12.5%) and predicted a subsequent INR of ≥6.0 (positive likelihood ratio of 4.2). CONCLUSION: Daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients.
BACKGROUND: The optimum international normalized ratio (INR) monitoring frequency for hospitalized patients receiving warfarin is unknown. OBJECTIVE: Assess relationship between daily versus less frequent INR monitoring and overanticoagulation and warfarin-related adverse events. DESIGN: Retrospective cohort study using Medicare Patient Safety Monitoring System data. SETTING: Randomly selected acute care hospitals across the United States. PATIENTS: Patients hospitalized from 2009 to 2013 for pneumonia, acute cardiac disease, or surgery who received warfarin. INTERVENTIONS: None. MEASUREMENTS: (1) Association between frequency of INR monitoring and an INR ≥6.0 or warfarin-related adverse event. (2) Association between the rate of change of the INR and a subsequent INR ≥5.0 and ≥6.0. RESULTS: Among 8529 patients who received warfarin for ≥3 days, for 1549 (18.2%) the INR was not measured on 2 or more days. These patients had higher propensity-adjusted odds ratios (ORs) of having a warfarin-associated adverse event (OR: 1.48, 95% confidence interval [CI]: 1.02-2.17) for cardiacpatients and surgical patients (OR: 1.73, 95% CI: 1.20-2.48), with no significant association for pneumoniapatients. Cardiac and pneumoniapatients with 1 day or more without an INR measurement had higher propensity-adjusted ORs of having an INR ≥6.0 (OR: 1.61, 95% CI: 1.07-2.41 and OR: 1.92, 95% CI: 1.36-2.71, respectively). A 1-day increase in the INR of ≥0.9 occurred in 621 patients (12.5%) and predicted a subsequent INR of ≥6.0 (positive likelihood ratio of 4.2). CONCLUSION: Daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients.
Authors: Lisa B E Shields; Paula Fowler; Diane M Siemens; Douglas J Lorenz; Kenneth C Wilson; Steven T Hester; Joshua T Honaker Journal: BMC Fam Pract Date: 2019-11-07 Impact factor: 2.497
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