Elsevier

The American Journal of Medicine

Volume 130, Issue 3, March 2017, Pages 365.e7-365.e12
The American Journal of Medicine

AJM online
Clinical research study
Improving Warfarin Management Within the Medical Home: A Health-System Approach

https://doi.org/10.1016/j.amjmed.2016.09.030Get rights and content

Abstract

Background

Anticoagulation clinics have been considered the optimal strategy for warfarin management with demonstrated improved patient outcomes through increased time in therapeutic international normalized ratio (INR) range, decreased critical INR values, and decreased anticoagulation-related adverse events. However, not all health systems are able to support a specialized anticoagulation clinic or may see patient volume exceed available anticoagulation clinic resources. The purpose of this study was to utilize an anticoagulation clinic model to standardize warfarin management in a primary care clinic setting.

Methods

A warfarin management program was developed that included standardized patient assessment, protocolized warfarin-dosing algorithm, and electronic documentation and reporting tools. Primary care clinics were targeted for training and implementation of this program.

Results

The warfarin management program was applied to over 2000 patients and implemented at 39 clinic sites. A total of 160 nurses and 15 pharmacists were trained on the program. Documentation of warfarin dose and date of the next INR increased from 70% to 90% (P <.0001), documentation occurring within 24 hours of the INR result increased from 75% to 87% (P <.0001), and monitoring the INR at least every 4 weeks increased from 71% to 83% (P <.0001) per patient encounter. Time in therapeutic INR range improved from 65% to 75%.

Conclusion

Incorporating a standardized approach to warfarin management in the primary care setting significantly improves warfarin-related documentation and time in therapeutic INR range.

Section snippets

Standardizing Warfarin Management

The AAC created a workgroup to spearhead this initiative. The workgroup was led by the Anticoagulation Stewardship Program pharmacist and included primary care physicians, frontline nurses and pharmacists, clinic operations managers, and technical system support members.

The workgroup identified best practices through a comprehensive literature and Web search of published warfarin management guidelines and protocols. From there a delegation protocol was created that allowed physicians to

Results

In the fall of 2009, the AAC workgroup created a delegation protocol for warfarin management. It provides step-by-step instructions on how to initiate a patient on warfarin therapy, complete a patient assessment (Figure), calculate warfarin dose adjustments, and monitor an INR; it defines what information should be documented in the EMR and outlines patient education needs. The protocol was approved for use by our AAC Committee, Pharmacy and Therapeutics Committee, and Medical Board. The

Discussion

Our study shows that the implementation of a standardized warfarin management program across a health system was successful in improving the TTR. Additionally, implementing a standardized electronic documentation system also improved the documentation of the warfarin management plan, including: indication, INR goal, warfarin dose, and time to next INR, and allowed all providers access to the warfarin management information. It also provided the opportunity to create real-time registries for

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Cited by (0)

Funding: None.

Conflict of Interest: All authors confirm no conflicts of interest.

Authorship: All authors had access to the data and had a role in development of the study, access to, and evaluation of the study data and in preparation and review of the manuscript.

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