Adam J Rose1,2, Angela Park3, Christopher Gillespie1, Carol Van Deusen Lukas1,4, Al Ozonoff1,5,6, Beth Ann Petrakis1, Joel I Reisman1, Ann M Borzecki1,2,4, Ashley J Benedict7, William N Lukesh3, Timothy J Schmoke3, Ellen A Jones8, Anthony P Morreale9, Heather L Ourth10, James E Schlosser11, Michael F Mayo-Smith12, Arthur L Allen13, Daniel M Witt14, Christian D Helfrich15,16, Megan B McCullough1,4. 1. 1 Bedford VA Medical Center, MA, USA. 2. 2 Boston University School of Medicine, MA, USA. 3. 3 New England Veterans Engineering Resource Center, Boston, MA, USA. 4. 4 Boston University School of Public Health, MA, USA. 5. 5 Boston Children's Hospital, MA, USA. 6. 6 Harvard Medical School, Boston, MA, USA. 7. 7 VA Sunshine Healthcare Network, St Petersburg, FL, USA. 8. 8 VA Central Western Massachusetts Healthcare System, Northampton, MA, USA. 9. 9 VA Pharmacy Benefits Management Services, San Diego, CA, USA. 10. 10 VA Pharmacy Benefits Management Services, Hines, IL, USA. 11. 11 Manchester VA Medical Center, NH, USA. 12. 12 VA New England Healthcare System, Bedford, MA, USA. 13. 13 VA Salt Lake City Healthcare System, UT, USA. 14. 14 University of Utah College of Pharmacy, Salt Lake City, UT, USA. 15. 15 VA Portland Healthcare System, OR, USA. 16. 16 VA Center for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
Abstract
BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
Entities:
Keywords:
anticoagulants; implementation science; quality of health care; warfarin
Authors: Adam J Rose; Robert Goldberg; David D McManus; Alok Kapoor; Victoria Wang; Weisong Liu; Hong Yu Journal: J Am Heart Assoc Date: 2019-08-23 Impact factor: 5.501