Improving Anticoagulation Control Among Patients Treated with Warfarin

Adam J. Rose, MD, MSc, spent more than a decade of his professional life working to improve anticoagulation control among patients treated with warfarin in the Veterans Health Administration (VA). As an investigator at the VA Center for Healthcare Organization and Implementation Research, he helped lead a program that compared how quality measures designed to increase time in therapeutic range (TTR) at the New England region VA with the care patients on warfarin received at 116 other VA sites across the country.

Dr. Rose took a few minutes to discuss the quality improvement program and how its promising results have had a positive impact throughout the VA that extends beyond best practices in warfarin management.

What was the starting point for the study?

We began the program by finding factors that would improve TTR, which is convenient to measure. The VA is a wonderful lab for that, because there are hundreds of sites of care, and each one has its own way of doing things. We found that VA sites vary as much as 20% in percentage TTR, so we used that intermediate outcome as an anchor to assess processes of care. Professionals in the discipline of quality measurement often focus on the impact of cancer screenings, blood pressure control, and diabetes measurement. Quality measures are needed to assess rates of complications and outcomes related to warfarin therapy. That’s what we did.

How did you attempt to improve anticoagulation control across the health system?

We did a deep dive to look at structures of care at 3 VA sites that had the best TTR and 3 sites that had the worst TTR, and looked at how the delivery of care differed among the facilities. We put the findings into action by partnering with the VA in the New England region. With support from the division’s pharmacy service and administration, along with a research grant from the VA, we focused on processes of care at the site level—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—to examine changes in anticoagulation control, measured as percentage TTR.

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What did you discover about the effectiveness of the program?

TTR improved by 3.9% in the New England region and .4% across the rest of the VA sites. We had hoped for more of an improvement, but it was a statistically significant difference. Anecdotally, warfarin management across the sites became more like what we initially observed at the best performing sites of care. The old quality measurement system for VA anticoagulation has been retired—the entire VA is now implementing the quality measures and we’re continuing to see improvements in warfarin management across the entire system.

Did the role of the health-system’s pharmacists evolve during the program’s implementation?

Asking hospital pharmacists to manage clinical conditions is a fairly new concept, and the VA pharmacists were accustomed to being examined based on traditional pharmacy measures, such as the amount of time patients spend waiting at the window or stewardships of expensive therapies. The idea of measuring TTR and intermediate outcomes of care, and measuring processes of care that have been shown to improve TTR, is in line with how physicians and other direct caregivers are assessed.

Some of the pharmacists instinctually recognized it was a coming of age moment. They realized that working with quality measures was necessary if they wanted to be taken seriously as healthcare professionals. Pharmacists found the quality improvement program meaningful, challenging, and interesting, and were happy to be a part of it. Now, the program’s alums are bringing quality improvement to other aspects of clinical pharmacy throughout the VA.

What did you learn during the rollout and implementation of the program?

We now recommend that warfarin clinics employ pharmacy techs to answer the phones. It takes skill, training, and plenty of clinical judgment to handle incoming calls from patients. The program involved targeted audited feedback, which provided sites with real-time warfarin management improvements they needed to make. We were able to drill down into the program’s data to inform sites about how their warfarin management compared with other sites or their own past performance. The program also served as a patient registry, which enables sites to be proactive in addressing concerns about the care of specific patients. For example, providers can look up patients with TTR below 30% and call them in for a special visit to talk about their care. Should those patients be switched to a novel anticoagulant? Is there a good reason to keep them on warfarin? If so, what can be done to improve the therapy? Those are the types of issues the program’s participants were better able to work through with patients.

—Dan Cook

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