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Tran MH, Ourth HL, Morreale AP. Development and Implementation of National Time in Therapeutic Range Reports and Establishing Quality Standards Within Veterans Health Administration. J Gen Intern Med 2021; 36:1418-1421. [PMID: 33469776 PMCID: PMC8131411 DOI: 10.1007/s11606-020-06422-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Michael H Tran
- VA Pharmacy Benefits Management Services, Washington, DC, USA. .,VA Great Lakes Health Care System Pharmacy Benefits Management, Westchester, IL, USA.
| | - Heather L Ourth
- VA Pharmacy Benefits Management Services, Washington, DC, USA
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Rose AJ, Dunbar MS, Hughto JMW, Jasuja GK. Conceptual approach to developing quality measures for transgender patients. BMC Health Serv Res 2021; 21:152. [PMID: 33593361 PMCID: PMC7885225 DOI: 10.1186/s12913-021-06161-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/01/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Valid and reliable quality measures can help catalyze improvements in health care. The care of transgender patients is ripe for quality measurement, as there is increasing awareness of the increasing prevalence of this population and the urgency of improving the health care they receive. While best practices may not exist for some aspects of transgender health care, other aspects are characterized by well-developed and highly evidence-based recommendations. Our objective was to create a list of potential quality measures for transgender care. METHODS AND RESULTS In consultation with our advisory panel, which consisted of clinical and academic experts in transgender medicine, we selected eight prominent clinical practice guidelines of transgender health care for review. Our four team investigators carefully reviewed all eight clinical practice guidelines. Through the course of multiple consensus-building meetings, we iteratively refined items until we had agreed upon a list of forty potential quality measures, all of which met the criteria for quality measures set forth in the Center for Medicare and Medicaid Services Blueprint for developing quality measures. CONCLUSIONS This manuscript explains the origin of the quality measures we developed, and also provides a useful roadmap to any group hoping to develop quality measures for a field that has not previously had any.
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Affiliation(s)
- Adam J Rose
- Hebrew University School of Public Health, Jerusalem, Israel.
| | - Michael S Dunbar
- RAND Corporation, 4750 Fifth Avenue, Suite, Pittsburgh, PA, 600, USA
| | | | - Guneet K Jasuja
- Bedford VA Medical Center, Bedford, MA, USA
- Boston University School of Public Health, Boston, MA, USA
- OptumLabs Visiting Scholar, OptumLabs, Eden Prairie, MN, USA
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Shilbayeh SAR, Ismail SAER. Patient experience with an educational mobile health application: A pilot study on usability and feasibility in a Saudi population. COGENT PSYCHOLOGY 2020. [DOI: 10.1080/23311908.2020.1843883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Sireen Abdul Rahim Shilbayeh
- Computer Science Department, College of Computer and Information Sciences, Princess Nourah Bint Abdulrahman University Riyadh, Saudi Arabia
| | - Sahar Abd El Rahman Ismail
- Department of Computer Science, College of Computer and Information Sciences, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
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Shilbayeh SAR. The Impact of a Pharmacist-led Warfarin Educational Video in a Saudi Setting. J Pharm Bioallied Sci 2020; 12:413-422. [PMID: 33679087 PMCID: PMC7909055 DOI: 10.4103/jpbs.jpbs_188_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/16/2020] [Accepted: 06/18/2020] [Indexed: 11/17/2022] Open
Abstract
Context: Internationally, various warfarin education strategies have been described in the medical literature and delivered by a variety of health-care providers. However, none of these were tested in a Saudi setting. Aim: The aim of this study was to assess the impact of pharmacist interventions via an educational video on improving patient knowledge of and satisfaction with warfarin therapy and the international normalized ratio (INR). Setting and Design: This study adopted a prospective pre- and posttest design and enrolled 91 patients from an anticoagulant clinic at King Khaled University Hospital in Riyadh, Saudi Arabia, between September 2017 and February 2018. Materials and Methods: All patients completed the Anticoagulation Knowledge Assessment (AKA) and Anti-Clot Treatment Satisfaction (ACTS) scales. Subsequently, the patients watched a 10-min educational video containing basic information regarding warfarin and were given relevant informative booklets. The patients were reassessed after a mean follow-up period of approximately 52 days. Results: In total, 85 patients completed the study. The impact of the intervention on patient knowledge was highly significant (mean difference = 17.7%, 95% confidence interval (CI) = 21.75–13.58, P < 0.000). In addition, the patients showed significant increases in their ACTS benefits subscale scores (mean difference = 0.73, 95% CI = 1.22–0.24, P = 0.004). Despite being long-term warfarin users, the patients’ INRs had a greater tendency to be within the target range after the intervention (56.63% ± 35% vs. 64.72% ± 35% of the time; mean difference, 8.1 percentage points; effect size = 0.23). However, there was no significant effect on patients’ perceptions of the warfarin burden. Conclusion: This study provided evidence that a pharmacist-led audiovisual intervention via an educational video coupled with an informational booklet effectively improved patients’ knowledge retention and satisfaction with warfarin therapy benefits. Longer studies are needed to determine the impact of this intervention on patients’ perceptions of warfarin burdens and their INRs.
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Affiliation(s)
- Sireen Abdul Rahim Shilbayeh
- Department of Pharmaceutical Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Shilbayeh SAR, Ibrahim AA. The anti-clot treatment scale (ACTS): validation of the translated Arabic version among patients undergoing warfarin therapy in Saudi Arabia. Health Qual Life Outcomes 2020; 18:215. [PMID: 32631346 PMCID: PMC7339378 DOI: 10.1186/s12955-020-01471-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Long-term anticoagulation therapy, particularly with warfarin, is usually associated with poor adherence and low patient satisfaction. However, previous studies have highlighted the possibility that individual perceptions of warfarin differ according to cultural practices. This study validated the psychometric properties of the translated Arabic version of the Anti-Clot Treatment Scale (ACTS) for patients on warfarin therapy in Saudi Arabia. Methods A cross-sectional multicenter study was conducted at the three main medical centers in Riyadh. Stratified sampling was employed to recruit Arabic-speaking patients who had been taking warfarin for a minimum of 3 months for any indication. The patients completed the specific ACTS along with the generic Treatment Satisfaction Questionnaire for Medication (TSQM 1.4) at two clinic visits. The psychometric performance of the ACTS was evaluated using well-established criteria: feasibility, reliability, and validity. Results One hundred thirty-six patients participated in the study (mean age: 50.68 ± 14.6 years; range: 19–97). Overall, the patients reported moderate Burdens and Benefits scores (44 ± 9.9 and 11.92 ± 2.4, respectively) compared to the reference range for each subscale (12–60 and 3–15, respectively); however, they reported lower Burdens scores than other populations. Consistent with the original ACTS validation study, the criteria for acceptability (data targeting, floor/ceiling effects, and skewness) were satisfied; in fact, the Arabic version exhibited better item- and scale-level distributions of data than versions in other languages. The ACTS subscales also demonstrated satisfactory test-retest reliability with significant intraclass correlation coefficients ((ICC ≥ 0.5); p < 0.001) and good internal consistency (all Cronbach’s alpha values exceeded 0.7). Exploratory factor analysis supported the 2-factor loading model. Interestingly, the Arabic version exhibited greater convergent validity with the TSQM subdomains (r = 0.61). Conclusions This study provides convincing evidence that the Arabic versions of both the ACTS Burdens and ACTS Benefits scales are equivalent to other versions in terms of psychometric performance, as measured using reliability and validity criteria. These properties support the great potential of the Arabic ACTS to accurately reflect patient satisfaction, identify aspects of treatment that need improvement in clinical practice, and compare treatment satisfaction across different anticoagulant therapies or cultures in research.
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Affiliation(s)
- Sireen Abdul Rahim Shilbayeh
- Department of Pharmaceutical Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh, 11671, Saudi Arabia.
| | - Alnada Abdalla Ibrahim
- Department of Pharmaceutical Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh, 11671, Saudi Arabia
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Gillespie C, Rose AJ, Petrakis BA, Jones EA, Park A, McCullough MB. Qualitative study of patient experiences of responsibility in warfarin therapy. Am J Health Syst Pharm 2018; 75:1798-1804. [DOI: 10.2146/ajhp170736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA
| | | | | | - Ellen A. Jones
- Central Western Massachusetts VA Medical Center, Leeds, MA
| | - Angela Park
- Central Western Massachusetts VA Medical Center, Leeds, MA
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Rose AJ, Vaiana M. Evidence-Based Best Practices for Outpatient Management of Warfarin. Ann Pharmacother 2018; 52:1042-1046. [PMID: 29890846 DOI: 10.1177/1060028018782473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Many best practices have been described for organizing a clinic to manage warfarin. Although these practices may have face validity, they may not be based on empirical analysis. Here, we describe our decade-long effort to apply the Structure-Process-Outcome model of quality measurement as a basis for measuring and improving outpatient warfarin management in the Veterans Health Administration. The purpose of the article is to raise awareness of this body of work with pharmacists who could potentially incorporate the findings of this work into their own practice settings. We conclude with concrete suggestions for immediate implementation in clinical settings.
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Affiliation(s)
- Adam J Rose
- 1 RAND Corporation, Boston, MA, USA.,2 Boston University School of Medicine, MA, USA
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Treatment Satisfaction Questionnaire for Medication: Validation of the Translated Arabic Version among Patients Undergoing Warfarin Therapy in Saudi Arabia. Value Health Reg Issues 2018; 16:14-21. [PMID: 29626737 DOI: 10.1016/j.vhri.2018.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 12/10/2017] [Accepted: 01/05/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To validate the psychometric properties of the translated Arabic version of the Treatment Satisfaction Questionnaire for Medication (TSQM 1.4) for patients on warfarin therapy in Saudi anticoagulation clinics (ACCs). METHODS A cross-sectional survey was conducted at the Security Forces Hospital ACC in Riyadh, Saudi Arabia. It involved administering questionnaires related to patients' satisfaction and assessing adherence through interviews. The quality of the international normalized ratio control was assessed using the Rosendaal method. A psychometric evaluation of TSQM 1.4 was carried out, addressing internal consistency and known-groups and convergent validity. RESULTS A total of 101 patients completed the questionnaire with an 80% response rate. The independent Cronbach α values for the effectiveness, side effects, and global satisfaction domains were consistently higher than 0.75, demonstrating good internal consistency and suitability of these domains for application in the current patients' setting. When these domains were used together in a multivariable logistic regression model of adherence, the only domain that remained significant was TSQM effectiveness (P = 0.017). Interestingly, a higher likelihood of moderate to optimal international normalized ratio control was significantly and independently associated with increased satisfaction scores in the effectiveness and convenience domains, but not in the side effects and global satisfaction domains. CONCLUSIONS This study provides evidence in favor of the reliability and validity of the Arabic version of TSQM 1.4 as a useful measure of satisfaction with anticoagulant therapy in patients visiting ACCs. The TSQM subscales in this patient setting seem to detect a clinically meaningful change over time, enhancing the potential of their use in routine practice.
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Chartrand M, Guénette L, Brouillette D, Côté S, Huot R, Landry J, Martineau J, Perreault S, White-Guay B, Williamson D, Martin É, Gagnon MM, Lalonde L. Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation. J Manag Care Spec Pharm 2018; 24:357-365. [PMID: 29578847 PMCID: PMC10397915 DOI: 10.18553/jmcp.2018.24.4.357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose. OBJECTIVE To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF). METHODS Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each. RESULTS The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients. CONCLUSIONS A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF. DISCLOSURES This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.
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Affiliation(s)
- Mylène Chartrand
- University of Montreal Hospital Research Center and Faculty of Pharmacy, University of Montreal, Quebec, Canada
| | - Line Guénette
- Faculty of Pharmacy, Université Laval, and Population Health and Optimal Health Practices Research Unit, Centre de recherche du Centre hospitalier universitaire de Québec-Université Laval, Quebec, Canada
| | | | | | - Roger Huot
- Montreal Heart Institute and Faculty of Medicine, University of Montreal, Quebec, Canada
| | - Jérôme Landry
- Pharmacy Veronic Comtois, Gabrielle Landry & Nathalie Ouellet pharmaciennes, Saint-Jean-de-Matha, Quebec, Canada
| | - Josée Martineau
- Department of Pharmacy Services, Hôpital de la Cité-de-la-Santé de Laval, Laval, Canada
| | | | - Brian White-Guay
- Faculty of Pharmacy and Faculty of Medicine, University of Montreal, and UMF-GMF Clinique de médecine familiale Notre-Dame, Montreal, Quebec, Canada
| | - David Williamson
- Faculty of Pharmacy, University of Montreal, and Department of Pharmacy Services and Research Center, Hôpital du Sacré-Coeur de Montréal, Quebec, Canada
| | | | | | - Lyne Lalonde
- University of Montreal Hospital Research Center and Faculty of Pharmacy, University of Montreal, Quebec, Canada
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Shilbayeh SAR, Almutairi WA, Alyahya SA, Alshammari NH, Shaheen E, Adam A. Validation of knowledge and adherence assessment tools among patients on warfarin therapy in a Saudi hospital anticoagulant clinic. Int J Clin Pharm 2017; 40:56-66. [PMID: 29189976 DOI: 10.1007/s11096-017-0569-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/23/2017] [Indexed: 12/13/2022]
Abstract
Background Although it can result in serious complications due to its narrow therapeutic index, warfarin is widely used in the treatment and prevention of thromboembolic disorders. However, patients' adherence and knowledge are determinants of therapeutic success. Objective We sought to validate instruments to provide a reliable means of identifying gaps in patient understanding and nonadherence to inform targeted pharmacists' interventions to improve these measures. Methods A cross-sectional survey was conducted. Patients' knowledge about warfarin was rated using an Arabic-language tool. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). The international normalized ratio (INR) control was quantified by the Rosendaal Method. Setting At the Security Forces hospital anticoagulant clinic (ACC), Riyadh. Main outcome measure Validity of a Knowledge and adherence tool. Results Totally, 101 patients completed the questionnaires. Interestingly, the knowledge tool demonstrated good internal consistency (total Cronbach's alpha = 0.75) and significant concurrent validity with adherence levels. Fifty-two patients were classified as having unsatisfactory knowledge. Deficiency in knowledge was most obvious with respect to the consequences of missing a dose and when to seek immediate medical attention. The MMAS-8 had moderate reliability (Cronbach's alpha = 0.65); however, its concurrent validity with good INR control was not demonstrated. Conclusions This study revealed high prevalence of nonadherence and poor knowledge in the population visiting the ACC. Given that available knowledge and adherence tools seemed to have little validity in predicting clinical outcomes, structured tools should be designed, considering progression in clinical outcomes with future pharmacists' interventions.
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Affiliation(s)
- Sireen Abdul Rahim Shilbayeh
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia.
| | - Wejdan Ali Almutairi
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia
| | - Sarah Ahmed Alyahya
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia
| | - Nouf Hayef Alshammari
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia
| | - Eiad Shaheen
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia
| | - Alya Adam
- Department of Pharmacy Practice,, Pharmacy College Princess Nourah bint Abdul Rahman University, Riyadh, 11671, P.O. Box 84428, Saudi Arabia
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Petit-Monéger A, Thiessard F, Noize P, Berdaï D, Jouhet V, Saillour-Glénisson F, Salmi LR. Definition of indicators of the appropriateness of oral anticoagulant prescriptions in hospitalized adults: Literature review and consensus (PACHA study). Arch Cardiovasc Dis 2017; 111:155-171. [PMID: 28943263 DOI: 10.1016/j.acvd.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 04/13/2017] [Accepted: 05/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Indicators of the appropriateness of oral anticoagulant prescriptions are lacking, despite the major contribution they could make to improve quality of care. AIM To identify and select such indicators according to their utility and operational implementation. METHODS A literature review was conducted to identify indicators of the appropriateness of oral anticoagulant prescriptions according to the guidelines of health authorities and European learned societies. A first list of indicators was identified from guidelines related to general or targeted clinical situations. A two-round Delphi consensus process, completed by a synthesis meeting, was then set up to ask European experts to rate the utility and operational implementation of the indicators on a qualitative binary scale. An indicator was selected if ≥80% of the experts judged it both useful and implementable (strong consensus). RESULTS We selected 32 references, from which 84 indicators were identified. Nineteen indicators were short-listed for submission to expert judgment. Twenty-two experts participated in the Delphi process. Sixteen indicators obtained strong consensus for selection; three indicators did not achieve consensus. Two-thirds of the selected indicators focused on the appropriateness of oral anticoagulant prescriptions in general or in patients with atrial fibrillation; the other third focused on the appropriateness of prescriptions in patients with a prosthetic heart valve, venous thromboembolism or trauma. CONCLUSION This work addresses the current lack of indicators of the appropriateness of oral anticoagulant prescriptions. The selected indicators will be implemented from the hospital information system to assess their metrological properties to detect inappropriate prescriptions.
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Affiliation(s)
- Aurélie Petit-Monéger
- CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France.
| | - Frantz Thiessard
- CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France
| | - Pernelle Noize
- Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France; Service de pharmacologie médicale, pôle de santé publique, CHU de Bordeaux, 33000 Bordeaux, France
| | - Driss Berdaï
- Service de pharmacologie médicale, pôle de santé publique, CHU de Bordeaux, 33000 Bordeaux, France
| | - Vianney Jouhet
- CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France
| | - Florence Saillour-Glénisson
- CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France
| | - Louis-Rachid Salmi
- CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Centre Inserm U1219 Bordeaux Population Health, université de Bordeaux, ISPED, 33076 Bordeaux, France; Inserm, ISPED, centre Inserm U1219 Bordeaux Population Health, 33076 Bordeaux, France
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Mohammad I, Korkis B, Garwood CL. Incorporating Comprehensive Management of Direct Oral Anticoagulants into Anticoagulation Clinics. Pharmacotherapy 2017; 37:1284-1297. [DOI: 10.1002/phar.1991] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Insaf Mohammad
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
| | - Bianca Korkis
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
- Department of Pharmacy Practice; Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University; Detroit Michigan
| | - Candice L. Garwood
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
- Department of Pharmacy Practice; Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University; Detroit Michigan
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Petit-Monéger A, Thiessard F, Jouhet V, Noize P, Berdaï D, Kret M, Sitta R, Salmi LR, Saillour-Glénisson F. Development and validation of hospital information system-generated indicators of the appropriateness of oral anticoagulant prescriptions in hospitalised adults: the PACHA study protocol. BMJ Open 2017; 7:e016488. [PMID: 28860229 PMCID: PMC5589008 DOI: 10.1136/bmjopen-2017-016488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION The appropriateness of oral anticoagulant prescriptions is a major challenge to improve quality and safety of care. As indicators of the appropriateness of oral anticoagulant prescriptions are lacking, the aim of the study is to develop and validate a panel of such indicators, in hospitalised adults, from the hospital information system of two university hospitals in France. METHODS AND ANALYSIS The study will be carried out in four steps: (1) a literature review to identify indicators of the appropriateness of oral anticoagulant prescriptions and their conditions of appropriateness; (2) a Delphi consensus method to assess the potential utility and operational implementation of the selected indicators; (3) techniques of medical data search to implement indicators from the hospital information system and; (4) a cross-sectional study to assess the ability of indicators to detect inappropriate oral anticoagulant prescriptions, performance of medical data search techniques for tracking or retrieving information and the ability of tools to be transferred into other institutions. The fourth step will include up to 80 patient hospital stays for each indicator, depending on the prevalence of inappropriate prescriptions estimated in interim analyses. ETHICS AND DISSEMINATION This work addresses the current lack of quality indicators of the appropriateness of oral anticoagulant prescriptions. We aim to develop and validate such indicators for integrating them into hospital clinical practice, as part of a structured approach to improve quality and safety of care. As each hospital information system is different, we will propose tools transferable to other healthcare institutions to allow an automated construction of these indicators. The PACHA study protocol was approved by institutional review boards and ethics committees (CPP Sud-Ouest et Outre Mer III-DC 2016/119; CPP Ile-de-France II-CDW_2016_0014). REGISTRATION DETAILS Clinical Trial.gov registration: NCT02898090.
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Affiliation(s)
- Aurélie Petit-Monéger
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Frantz Thiessard
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Vianney Jouhet
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Pernelle Noize
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- CHU de Bordeaux, Pôle de santé publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Driss Berdaï
- CHU de Bordeaux, Pôle de santé publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Marion Kret
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
| | - Rémi Sitta
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
| | - Louis-Rachid Salmi
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Florence Saillour-Glénisson
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
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Fenta TG, Assefa T, Alemayehu B. Quality of anticoagulation management with warfarin among outpatients in a tertiary hospital in Addis Ababa, Ethiopia: a retrospective cross-sectional study. BMC Health Serv Res 2017; 17:389. [PMID: 28587606 PMCID: PMC5461683 DOI: 10.1186/s12913-017-2330-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Warfarin is the most widely used anticoagulant in the world. The difficulty of managing warfarin contributes to great potential for patient harm, both from excessive anticoagulation and insufficient anticoagulation. This study assessed the International Normalized Ratio (INR) control outcome measures and warfarin dose adjustment practices at cardiology and hematology outpatient clinics at a teaching hospital in Addis Ababa, Ethiopia. Methods The study was based on a cross - sectional study design involving 360 retrospective patients’ chart review among outpatients who received warfarin for its various indications. Results The mean frequency of INR monitoring per patient was 62.9 days (17.2–143.7 days). Patients spent 52.2%, 29.0% and 18.8% of the time in sub-therapeutic, therapeutic and supra-therapeutic ranges, respectively. The daily warfarin dose was increased 50.9% and 36.9% and decreased in 52.8% and 60.9% of the time for occurrences of sub-therapeutic and supra-therapeutic INRs to achieve target ranges of 2.0–3.0 and 2.5–3.5, respectively. Conclusion The quality of anticoagulation management with warfarin among outpatients in Tikur Anbessa Specialized Hospital was sub-optimal. This was reflected by low Time in Therapeutic Range (TTR), longer than recommended INR monitoring frequency, and minimal actions taken to adjust warfarin dose after occurrences of non-therapeutic INRs.
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Affiliation(s)
- Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Tamrat Assefa
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bekele Alemayehu
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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McCullough MB, Gillespie C, Petrakis BA, Jones EA, Park AM, Lukas CV, Rose AJ. Forming and activating an internal facilitation group for successful implementation: A qualitative study. Res Social Adm Pharm 2017; 13:1014-1027. [PMID: 28434918 DOI: 10.1016/j.sapharm.2017.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 03/19/2017] [Accepted: 04/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration (VA) medical centers. Other studies have explored various models of implementation facilitation, including external facilitation (EF), internal facilitation (IF), and blended facilitation (BF) combining both approaches. This study focuses on the use of an internal facilitation team of anticoagulation coordinators representing 8 VA anticoagulation clinics to enhance the implementation process. This study examines how the team became instrumental in the successful implementation of evidence-based practice change. METHODS Semi-structured interviews were conducted annually over 4 years with representatives from each site, the internal facilitators (site champions), at 8 VA hospitals (47 interviews). Additionally, five external facilitators, experts in quality improvement and anticoagulation care who guided the implementation, were interviewed. Analysis drew on a deductive approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and emergent thematic analysis to identify factors related to effectiveness of the internal facilitation team. RESULTS Key findings are that the following factors enhanced successful uptake of the anticoagulation initiative: 1) Regular participation by the site champion in the internal facilitation team; 2) Champion strongly committed to being an agent of change; and 3) Champion received greater support from their supervisors. The first and second factors are interrelated, as internal facilitators who actively and regularly participated in the internal facilitation team often became truly committed to the improvement project. Both factors relate to the third, as supervisor support not only facilitated changes in practice, but also facilitated regular team attendance and stronger participation. CONCLUSIONS Our study adds to implementation science by detailing how internal facilitators learn their skills over time, and how a group of internal facilitators can help each other succeed. These findings can guide those who wish to incorporate internal facilitation teams as an implementation strategy, and demonstrate how sites can build capacity for implementation efforts. SYNOPSIS This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration medical centers. Internal facilitators (IFs) guided by and supported by an external facilitators (EF), successfully implemented the clinical innovation. This study examines how the IF group became instrumental in the successful implementation of evidence-based practice change.
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Affiliation(s)
- Megan B McCullough
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany St # 358w, Boston, MA, 02118, USA.
| | - Chris Gillespie
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA
| | - Beth Ann Petrakis
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA
| | - Ellen A Jones
- Central Western Massachusetts VA Healthcare System, 421 North Main Street, Leeds, MA, 01053, USA
| | - Angela M Park
- New England VERC, Boston VA Healthcare System, 1400 VFW Parkway, West Roxbury, MA, 02132, USA
| | - Carol VanDeusen Lukas
- VA HSR&D Center for Healthcare Organization and Implementation Research, VA Boston Medical Center, 1400 VFW Parkway, West Roxbury, MA, 02132, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany St # 358w, Boston, MA, 02118, USA
| | - Adam J Rose
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA; Department of Internal Medicine, Section of General Internal Medicine, Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
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Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA, Reisman JI, Borzecki AM, Benedict AJ, Lukesh WN, Schmoke TJ, Jones EA, Morreale AP, Ourth HL, Schlosser JE, Mayo-Smith MF, Allen AL, Witt DM, Helfrich CD, McCullough MB. Results of a Regional Effort to Improve Warfarin Management. Ann Pharmacother 2016; 51:373-379. [PMID: 28367699 DOI: 10.1177/1060028016681030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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.
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Affiliation(s)
- Adam J Rose
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA
| | - Angela Park
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Carol Van Deusen Lukas
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
| | - Al Ozonoff
- 1 Bedford VA Medical Center, MA, USA.,5 Boston Children's Hospital, MA, USA.,6 Harvard Medical School, Boston, MA, USA
| | | | | | - Ann M Borzecki
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA.,4 Boston University School of Public Health, MA, USA
| | | | - William N Lukesh
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Ellen A Jones
- 8 VA Central Western Massachusetts Healthcare System, Northampton, MA, USA
| | | | | | | | | | | | - Daniel M Witt
- 14 University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Christian D Helfrich
- 15 VA Portland Healthcare System, OR, USA.,16 VA Center for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Megan B McCullough
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
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Rose AJ, Delate T, Ozonoff A, Witt DM. Comparison of the Abilities of Summary Measures of International Normalized Ratio Control to Predict Clinically Relevant Bleeding. Circ Cardiovasc Qual Outcomes 2016; 8:524-31. [PMID: 26330391 DOI: 10.1161/circoutcomes.115.001768] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited research has compared the measures of summarizing international normalized ratio (INR) control over time. Measures that are more predictive of patient outcomes would be preferred as would those that are easier to calculate and understand. METHODS AND RESULTS We examined 676 patients who received long-term warfarin therapy to treat atrial fibrillation: 125 patients who experienced major hemorrhage and 551 matched controls who did not. Patient INR control was characterized using various measures, from simple (proportion of INR values in range) to complex (eg, area under the curve above target range, squared) measures. Conditional logistic regression was used to examine the ability of each measure to predict the outcome of clinically relevant bleeding across quintiles of control. All measures were associated with clinically relevant bleeding to some extent: patients with the poorest control had significantly more bleeding events compared with patients with the best control. The measure most strongly associated with bleeding was a combination of percent time in therapeutic range and INR variability (odds ratio of 4.34, comparing the lowest to the highest quintiles of control). The strongest single predictor was INR variability, followed closely by time in therapeutic range. More computationally complex measures, which had been expected to perform better, were not so strongly associated with bleeding. CONCLUSIONS INR variability was the most strongly associated predictor of clinically relevant bleeding followed closely by time in therapeutic range. Using both measures together had an even stronger association. These findings support continued use of INR variability, time in therapeutic range, or both for research and quality assurance efforts.
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Razouki Z, Burgess JF, Ozonoff A, Zhao S, Berlowitz D, Rose AJ. Improving Anticoagulation Measurement Novel Warfarin Composite Measure. Circ Cardiovasc Qual Outcomes 2016; 8:600-7. [PMID: 26420820 DOI: 10.1161/circoutcomes.115.001789] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percent time in therapeutic range (TTR) and international normalized ratio (INR) variability both measure warfarin control and are associated with outcomes independently. Here, we examine the advantages of a warfarin composite measure (WCM), which summarizes the 2 when measuring patient outcomes. We also examine how the measure chosen would affect anticoagulation clinic performance rankings. METHODS AND RESULTS We constructed WCM using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability using 103 897 warfarin-experienced patients from 100 anticoagulation clinics. We examined the association of WCM with ischemic stroke, major bleeding, and fatal bleeding, using a subset of patients with atrial fibrillation (n=40 404). We divided patients into quintiles based on their level of control for TTR, log INR variability, and WCM. We calculated the hazard ratios for ischemic stroke, major bleeding, and fatal bleeding stratified by these quintiles. WCM hazard ratios for stroke and fatal bleeding showed the largest difference between excellent control and poorest control quintile compared with TTR and log INR variability, but not for major bleeding. In addition, we compared site rankings obtained using each of our 3 performance measures. Kappa scores for identifying outlier and nonoutlier clinics between WCM and its components were moderate (κ=0.56 for TTR and κ=0.62 for log INR variability) but was weak between TTR and log INR variability (κ=0.13). CONCLUSIONS WCM produces the largest range of risk for warfarin complications, widening the floor ceiling effects that limit the use of TTR and INR variability as separate measures. Anticoagulation clinics ranking changed considerably according to the anticoagulation measure that was selected.
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Rose AJ, McCullough MB. A Practical Guide to Using the Positive Deviance Method in Health Services Research. Health Serv Res 2016; 52:1207-1222. [PMID: 27349472 DOI: 10.1111/1475-6773.12524] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To provide practical tips for health services researchers considering the use of positive deviance (PD) methods to help explain variations in quality of care or other meaningful parameters. DATA SOURCES Published literature and personal experience. STUDY DESIGN Narrative review. PRINCIPAL FINDINGS This review includes a discussion of possible applications of PD to health services research, some methodological choices applicable to PD, and some brief tips regarding publishing the results and incorporating them into future interventions. CONCLUSIONS It is hoped that this article will help health services researchers to use this valuable research method more effectively, especially those who have not done so before.
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Affiliation(s)
- Adam J Rose
- Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118.,Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA.,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA
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Rose AJ, Reisman JI, Razouki Z, Ozonoff A. Percent Time in Range with Warfarin as a Performance Measure: How Long a Sampling Frame Is Needed? Jt Comm J Qual Patient Saf 2016; 41:561-8. [PMID: 26567146 DOI: 10.1016/s1553-7250(15)41073-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Warfarin is received by millions of patients in the United States and elsewhere and will remain the most commonly used anticoagulant for the foreseeable future. Percent time in therapeutic range (TTR) with warfarin is increasingly used as a performance measure. However, stakeholders have expressed concern that TTR lags behind changes in performance. Work in a larger study focused on the impact of shortening the conventional measurement period for TTR. METHODS Some 124 sites within the Department of Veterans Affairs (VA) were examined during a seven-year period (fiscal years [FYs] 2008-2014 (April 1, 2007-September 30, 2014). The duration of time segments (2, 3, 4, 6 months) used to calculate TTR were varied, and these four durations were compared in terms of the number of patients retained per site, mean and median site TTR, and site performance rankings. RESULTS Data were obtained on 295,237 unique patients who received anticoagulation. As the calculation window shortened, patients with better control (that is, higher TTR) were selectively excluded from the measurement because their laboratory values were more widely spaced. Site mean TTR was highest when the most patients were included (6 months: 950 patients; TTR 65.2%) and lowest when the fewest patients were included (2 months: 567 patients; TTR 60.0%). However, the 3-, 4-, and 6-month segments achieved similar results, each of which included more than 800 patients per site, with mean TTR across a narrow range (64.9%-65.2%). Site rankings were less highly correlated between the 2-month period and longer periods (r = 0.7- 0.8) but were otherwise 0.95 or higher, with a nearly perfect correlation (0.985) between the 4- and 6-month periods. CONCLUSIONS When TTR is used to measure site-level performance, comparable results can be achieved using a 4- or a 6-month measurement period. On the basis of these results, the use of a 4-month period for future measurement efforts is recommended.
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Affiliation(s)
- Adam J Rose
- Center for Healthcare Organization and Implementation Research, Bedford Department of Veterans Affairs (VA) Medical Center, Bedford, Massachusetts, USA
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Abstract
Anticoagulants are highly effective at preventing thrombosis across a variety of clinical indications. However, their use can also lead to devastating effects, including major bleeding and death. Anticoagulation providers strive to balance the benefits of anticoagulant therapy with the risks of major bleeding. A measure of quality care can be used to assess the strengths and potential weaknesses in any system of coordinated care delivery. Quality measures in anticoagulation include patient-centered outcomes (e.g. major bleeding, time in the therapeutic range) and provider- or process-focused outcomes (e.g. compliance with guideline recommendations and response times to out-of-range laboratory values). Engaging in quality improvement activities allows anticoagulation providers to assess their own performance and identify areas for targeted interventions. This review summarizes the justification for engaging in quality improvement for anticoagulation management and describes a number of example programs. Interventions benefiting the management of both warfarin and the direct oral anticoagulants are included. The review also details potential quality measures and resources for any anticoagulation provider looking to begin a quality improvement process.
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Affiliation(s)
- Geoffrey D Barnes
- University of Michigan Cardiovascular Center (UM CVC), Domino's Farms, Lobby A, MCORRP, 24 Frank Lloyd Wright Dr., Ann Arbor, MI, 48106, USA,
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Ozkaynak M, Johnson SA, Tulu B, Donovan JL, Kanaan AO, Rose A. Exploring the effect of complex patients on care delivery tasks. Int J Health Care Qual Assur 2015; 28:494-509. [PMID: 26020430 DOI: 10.1108/ijhcqa-11-2014-0105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The needs of complex patients with chronic conditions can be unpredictable and can strain resources. Exploring how tasks vary for different patients, particularly those with complex needs, can yield insights about designing better processes in healthcare. The purpose of this paper is to explore the tasks required to manage complex patients in an anticoagulation therapy context. DESIGN/METHODOLOGY/APPROACH The authors analyzed interviews with 55 staff in six anticoagulation clinics using the Systems Engineering Initiative for Patient Safety (SEIPS) work system framework. The authors qualitatively described complex patients and their effects on care delivery. FINDINGS Data analysis highlighted how identifying complex patients and their effect on tasks and organization, and the interactions between them was important. Managing complex patients required similar tasks as non-complex patients, but with greater frequency or more intensity and several additional tasks. After complex patients and associated patient interaction and care tasks were identified, a work system perspective was applied to explore how such tasks are integrated within clinics and the resulting implications for resource allocation. PRACTICAL IMPLICATIONS The authors present a complex patient management framework to guide workflow design in specialty clinics, to better support high quality, effective, efficient and safe healthcare. ORIGINALITY/VALUE The complex patient framework presented here, based on the SEIPS framework, suggests a more formal and integrated analysis be completed to provide better support for appropriate resource allocation and care coordination.
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Blissit KT, Mullenix ML, Brittain KG. Evaluation of Time in Therapeutic Range on Warfarin Therapy Between Face-to-Face and Telephone Follow-Up in a VA Medical Center. J Pharm Technol 2015; 31:78-83. [PMID: 34860994 DOI: 10.1177/8755122514552497] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Few studies have evaluated percent time in therapeutic range (TTR) for warfarin managed via face-to-face (FF) to telephone (TELE) visits-all finding no difference between groups. Objective: Compare and evaluate TTR for warfarin in patients who received pharmacist-managed care via FF or TELE. Methods: Single-center, retrospective study. Eligible participants were ≥18 years old, on indefinite warfarin therapy, followed by clinical pharmacists via FF or TELE from 2010 to 2012. Primary outcome (TTR) calculated via Rosendaal method. Event data included rates of any bleeding, significant bleeding, deep vein thrombosis, pulmonary embolism, cerebrovascular accident, hospitalizations, and death. Clinics were also compared by location. Results: Two hundred subjects (90 FF and 110 TELE) were included. Mean TTR was 68.17% and 69.57% in FF and TELE groups, respectively. The FF group had statistically significant higher rates of any bleeding (48.9% vs 30.9%). Rates of significant bleeding in FF versus TELE were not significantly different (6.67% vs 2.73%). The majority followed FF with significant bleeding were at a higher bleeding risk than those followed via TELE. There were low rates of venous thromboembolism (1.1% and 1.8%). Conclusions: TTR was ≥65% for most subjects with minimal variability in TTR between clinics. Mean TTR results for each group were greater and above the threshold that has been commonly described in the literature as quality control, suggesting a progression in implementation of telephone-based anticoagulation management.
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Affiliation(s)
- Katie T Blissit
- William Jennings Bryan Dorn VA Medical Center, Columbia, SC, USA
| | | | - Kevin G Brittain
- William Jennings Bryan Dorn VA Medical Center, Columbia, SC, USA
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McCullough MB, Chou AF, Solomon JL, Petrakis BA, Kim B, Park AM, Benedict AJ, Hamilton AB, Rose AJ. The interplay of contextual elements in implementation: an ethnographic case study. BMC Health Serv Res 2015; 15:62. [PMID: 25890333 PMCID: PMC4345021 DOI: 10.1186/s12913-015-0713-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/19/2015] [Indexed: 11/17/2022] Open
Abstract
Background Contextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative. Methods We completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis. Results Key contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak. Conclusion Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.
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Affiliation(s)
- Megan B McCullough
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, Bedford, MA, USA.
| | - Ann F Chou
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Jeffrey L Solomon
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, Bedford, MA, USA.
| | - Beth Ann Petrakis
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, Bedford, MA, USA.
| | - Bo Kim
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, Bedford, MA, USA.
| | | | | | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles, Los Angeles, CA, USA. .,University of California, LA, Los Angeles, CA, USA.
| | - Adam J Rose
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, Bedford, MA, USA. .,Boston University School of Medicine, Boston, MA, USA.
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Rao SR, Reisman JI, Kressin NR, Berlowitz DR, Ash AS, Ozonoff A, Miller DR, Hylek EM, Zhao S, Rose AJ. Explaining Racial Disparities in Anticoagulation Control. Am J Med Qual 2014; 30:214-22. [DOI: 10.1177/1062860614526282] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sowmya R. Rao
- Bedford VA Medical Center, Bedford, MA
- University of Massachusetts Medical School, Worcester, MA
| | | | - Nancy R. Kressin
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Dan R. Berlowitz
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Medicine, Boston, MA
- Boston University School of Public Health, Boston, MA
| | - Arlene S. Ash
- Bedford VA Medical Center, Bedford, MA
- University of Massachusetts Medical School, Worcester, MA
| | - Al Ozonoff
- Bedford VA Medical Center, Bedford, MA
- Boston Children’s Hospital, Boston, MA
| | - Donald R. Miller
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Public Health, Boston, MA
| | | | | | - Adam J. Rose
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Medicine, Boston, MA
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Affiliation(s)
- Adam J Rose
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Road, Mail Stop 152, Bedford, MA, 01730, USA,
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Cancino RS, Hylek EM, Reisman JI, Rose AJ. Comparing patient-level and site-level anticoagulation control as predictors of adverse events. Thromb Res 2014; 133:652-6. [PMID: 24502961 DOI: 10.1016/j.thromres.2014.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 01/02/2014] [Accepted: 01/06/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Percent time in therapeutic range (TTR) is increasingly used to summarize anticoagulation control over time among patients receiving warfarin. Higher TTR improves outcomes of care, but studies have varied regarding whether TTR is best summarized as center-based percent time in therapeutic range (cTTR) or as individual percent time in therapeutic range (iTTR). Our aim was to compare cTTR to iTTR in predicting ischemic stroke, major hemorrhage, and all-cause mortality. MATERIALS AND METHODS Veterans Health Administration data of 57,281 patients receiving warfarin therapy were included. iTTR was calculated using linear interpolation. Each site's mean TTR was calculated, and the cTTR was assigned to all patients at that site. We used Cox proportional hazards to examine cTTR and iTTR as predictors of major hemorrhage, ischemic stroke, and all-cause mortality. RESULTS Comparing worst to best quartiles of INR control, cTTR was not a statistically significant predictor of major hemorrhage or ischemic stroke, hazard ratios (HR) were 1.02 (95% confidence interval [CI] 0.93-1.11) and 1.00 (95% CI: 0.88-1.13), respectively. cTTR was a weak predictor of all-cause mortality (HR: 1.14, 95% CI: 1.07-1.22). iTTR predicted major hemorrhage (HR: 1.79, 95% CI: 1.63-1.96), ischemic stroke (HR: 1.91, 95% CI: 1.67-2.19), and all-cause mortality (HR: 2.20, 95% CI: 2.05-2.35). CONCLUSION iTTR significantly predicted risk of major hemorrhage, ischemic stroke, and all-cause mortality. cTTR was a weak predictor of all-cause mortality. Though cTTR may be a better target for site-level quality improvement efforts, iTTR may be a more suitable measure for use in comparative effectiveness research.
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Affiliation(s)
- Ramon S Cancino
- Department of Family Medicine, Boston University School of Medicine, Boston, MA, United States.
| | - Elaine M Hylek
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, United States; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, United States
| | - Adam J Rose
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, United States; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, United States
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Qualls LG, Greiner MA, Eapen ZJ, Fonarow GC, Mills RM, Klaskala W, Hernandez AF, Curtis LH. Postdischarge international normalized ratio testing and long-term clinical outcomes of patients with heart failure receiving warfarin: findings from the ADHERE registry linked to Medicare claims. Clin Cardiol 2013; 36:757-65. [PMID: 24114926 DOI: 10.1002/clc.22206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/15/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Effective warfarin thromboprophylaxis requires maintaining anticoagulation within the recommended international normalized ratio (INR) range. INR testing rates and associations between testing and outcomes are not well understood. HYPOTHESIS INR testing rates after hospitalization for acute decompensated heart failure are suboptimal, and testing is associated with lower risks of mortality and adverse clinical events. METHODS We conducted a retrospective cohort study of patients who were long-term warfarin users and were hospitalized for heart failure, had a medical history of atrial fibrillation or valvular heart disease, and were enrolled in fee-for-service Medicare. INR testing was defined as ≥1 outpatient INR test within 45 days after discharge. Using Cox proportional hazards models, we examined associations between testing and all-cause mortality, all-cause readmission, and adverse clinical events at 1 year. RESULTS Among 8558 patients, 7722 (90.2%) were tested. After 1 year, tested patients had lower all-cause mortality (23.5% vs 32.6%; P < 0.001) and fewer myocardial infarctions (2.0% vs 3.3%; P = 0.02). These differences remained significant after multivariable adjustment with hazard ratios of 0.72 (95% confidence interval [CI]: 0.63-0.84; P < 0.001) and 0.58 (95% CI: 0.41-0.83; P = 0.003), respectively. Differences in all-cause readmission, thromboembolic events, ischemic stroke, and bleeding events were not statistically significant. CONCLUSIONS Postdischarge outpatient INR testing in patients with heart failure complicated by atrial fibrillation or valvular heart disease was high. INR testing was associated with improved survival and fewer myocardial infarctions at 1 year but was not independently associated with other adverse clinical events.
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Affiliation(s)
- Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Affiliation(s)
- Deborah Cohen
- Department of Population Health, University of Ottawa, Ottawa, Ontario, Canada
- Canadian Institute for Health Information, Ottawa, Ontario, Canada
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Rose AJ, Miller DR, Ozonoff A, Berlowitz DR, Ash AS, Zhao S, Reisman JI, Hylek EM. Gaps in monitoring during oral anticoagulation: insights into care transitions, monitoring barriers, and medication nonadherence. Chest 2013. [PMID: 23187457 DOI: 10.1378/chest.12-1119] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Among patients receiving oral anticoagulation, a gap of > 56 days between international normalized ratio tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events. METHODS We studied long-term oral anticoagulation care for 56,490 patients aged 65 years and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percentage time in therapeutic range (TTR) at the 100 sites. RESULTS Many patients (45%) had at least one gap in monitoring during an average of 1.6 years of observation; 5% had two or more gaps per year. The median gap duration was 74 days (interquartile range, 62-107). The average TTR for patients with two or more gaps per year was 10 percentage points lower than for patients without gaps (P < .001). Patient-level predictors of gaps included nonwhite race, area poverty, greater distance from care, dementia, and major depression. Site-level gaps per patient-year varied from 0.19 to 1.78; each one-unit increase was associated with a 9.2 percentage point decrease in site-level TTR (P < .001). CONCLUSIONS Site-level gap rates varied widely within an integrated care system. Sites with more gaps per patient-year had worse anticoagulation control. Strategies to address and reduce gaps in monitoring may improve anticoagulation control.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston.
| | - Donald R Miller
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Health Policy and Management, Boston University School of Public Health, Boston
| | - Al Ozonoff
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Biostatistics Section, Boston Children's Hospital, Boston
| | - Dan R Berlowitz
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston; Department of Health Policy and Management, Boston University School of Public Health, Boston
| | - Arlene S Ash
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston; Department of Quantitative Health Sciences (Dr Ash), Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, MA
| | - Shibei Zhao
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford
| | - Joel I Reisman
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford
| | - Elaine M Hylek
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston
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Witt DM, Delate T, Clark NP, Garcia DA, Hylek EM, Ageno W, Dentali F, Crowther MA. Nonadherence with INR monitoring and anticoagulant complications. Thromb Res 2013; 132:e124-30. [PMID: 23800635 DOI: 10.1016/j.thromres.2013.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 05/23/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This study tests the hypothesis that nonadherence with INR monitoring is associated with an increased risk for warfarin-related bleeding and thrombosis and describes patient characteristics associated with INR monitoring nonadherence. MATERIALS AND METHODS This was a retrospective, longitudinal, matched cohort study wherein patients were categorized into adherent and nonadherent cohorts; adherent patients were matched 2:1 to nonadherent patients. The primary study endpoint was the first occurrence of bleeding or thromboembolism. Multivariate logistic regression modeling identified patient characteristics associated with INR monitoring adherence or nonadherence. RESULTS A total of 4995 and 2544 patients contributed 10729 and 5385 patient-years of warfarin therapy in the adherent and nonadherent groups, respectively. The rate of thromboembolic events during follow up was higher in the nonadherent group than in the adherent group (0.95% vs. 0.62% per patient-year, respectively; p=0.019) and nonadherence to INR monitoring was associated with a moderately higher risk of thromboembolism (adjusted Hazard Ratio=1.51; 95% confidence interval=1.04 - 2.20). The difference in bleeding between the two groups was not statistically significant. CONCLUSIONS Repeatedly missing INR tests is an easily identified clinical parameter that is associated with moderately increased risk for thromboembolism in patients taking chronic warfarin therapy. Clinicians should carefully consider the underlying thromboembolic risk and extent of nonadherence when weighing the benefits of continued warfarin therapy for a given patient.
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Affiliation(s)
- Daniel M Witt
- Kaiser Permanente Colorado Clinical Pharmacy Research Team, Aurora, CO; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Denver, CO.
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Nutescu EA, Bautista A, Gao W, Galanter WL, Schumock GT, Mody SH, Bookhart BK, Lambert BL. Warfarin anticoagulation after total hip or total knee replacement: Clinical and resource-utilization outcomes in a university-based antithrombosis clinic. Am J Health Syst Pharm 2013; 70:423-30. [DOI: 10.2146/ajhp120341] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Adriana Bautista
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Weihua Gao
- Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago
| | - William L. Galanter
- Department of Medicine, College of Medicine; Clinical Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Glen T. Schumock
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | | | - Brahim K. Bookhart
- Health Economics and Outcomes Research, Janssen Scientific Affairs, LLC, Raritan, NJ
| | - Bruce L. Lambert
- Department of Pharmacy Administration and Center for Education and Research on Therapeutics, University of Illinois at Chicago
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Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM, Bokhour BG. Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration. Health Serv Res 2012; 47:1541-60. [PMID: 22299722 DOI: 10.1111/j.1475-6773.2011.01377.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Anticoagulation clinics (ACCs) can improve anticoagulation control and prevent adverse events. However, ACCs vary widely in their performance on anticoagulation control. Our objective was to compare the organization and management of top-performing with that of bottom-performing ACCs. DATA SOURCES/STUDY SETTING Three high outlier and three low outlier ACCs in the Veterans Health Administration (VA). STUDY DESIGN Site visits with qualitative data collection and analysis. DATA COLLECTION/EXTRACTION METHODS We conducted semi-structured interviews with ACC staff regarding work flow, staffing, organization, and quality assurance efforts. We also observed ACC operations and collected documents, such as the clinic protocol. We used grounded thematic analysis to examine site-level factors associated with high and low outlier status. PRINCIPAL FINDINGS High outlier sites were characterized by (1) adequate (pharmacist) staffing and effective use of (nonpharmacist) support personnel; (2) innovation to standardize clinical practice around evidence-based guidelines; (3) the presence of a quality champion for the ACC; (4) higher staff qualifications; (5) a climate of ongoing group learning; and (6) internal efforts to measure performance. Although high outliers had all of these features, no low outlier had more than two of them. CONCLUSIONS The top-performing ACCs in the VA system shared six relatively recognizable characteristics. Efforts to improve performance should focus on these domains.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA 01730, USA.
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Rose AJ, Berlowitz DR, Ash AS, Ozonoff A, Hylek EM, Goldhaber-Fiebert JD. The business case for quality improvement: oral anticoagulation for atrial fibrillation. Circ Cardiovasc Qual Outcomes 2011; 4:416-24. [PMID: 21712521 DOI: 10.1161/circoutcomes.111.960591] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation. METHODS AND RESULTS Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR. CONCLUSIONS A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Road, Bedford, MA 01730, USA.
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Costa GLDB, Ferreira DC, Valacio RA, Vieira Moreira MDC. Quality of management of oral anticoagulation as assessed by time in therapeutic INR range in elderly and younger patients with low mean years of formal education: a prospective cohort study. Age Ageing 2011; 40:375-81. [PMID: 21422013 DOI: 10.1093/ageing/afr020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND despite the overwhelming evidence of its effectiveness, oral anticoagulation continues to be underused in the elderly, presumably due to physicians' misconceptions when estimating bleeding risk and ability to comply with treatment. OBJECTIVE to investigate the quality of anticoagulation control among deprived elderly and younger patients. DESIGN prospective observational study. SETTING a public anticoagulation clinic in a developing country. SUBJECTS all adult patients on intended long-term (>90 days) oral anticoagulation. We studied 171 patients (79 elderly and 92 non-elderly) with a mean follow-up of 273 ± 84.9 days. METHODS the main outcome measure was the quality of anticoagulation management as measured by the time in therapeutic (TTR) international normalised ratio (INR) range. Elderly patients (≥60 years) were compared with younger patients with respect to the educational level and co-morbidities. RESULTS the mean number of years of formal education was 4.37 ± 3.2 years. The mean TTR was 62.50 ± 17.9% in non-elderly and 62.10 ± 16.6% in elderly (P = 0.862) subjects, despite the higher prevalence of co-morbidities in the latter group: heart failure (46.3 versus 28.6%, P = 0.042), diabetes mellitus (22.8 versus 8.7%, P = 0.011), renal failure (estimated glomerular filtration rate <50 ml/min: 38.0 versus 7.1%, P < 0.001) and polypharmacy (84.8 versus 58.7%, P < 0.001). Fifty elderly and 84 non-elderly subjects require little or no assistance in taking medications. Among them, the elderly had lower educational levels (3.42 ± 2.5 versus 5.55 ± 3.4 years of formal education, P < 0.001) and higher rates of cognitive impairment (34.0 versus 13.1%, P = 0.004), but a similar mean TTR (62.46 ± 16.1 versus 63.02 ± 17.8%, P = 0.856). The oldest (≥75 years) patients did as well as those aged ≤50 years (mean TTR: 62.54 ± 16.0 versus 62.23 ± 16.4%, respectively, P = 0.98). CONCLUSIONS good-quality management of oral anticoagulation is achievable in deprived populations attending an anticoagulation clinic. Elderly patients may experience similar quality of anticoagulation despite having higher levels of co-morbidities and polypharmacy. These results add evidence to the safety of such therapeutic interventions in the elderly.
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Rose AJ, Hylek EM, Berlowitz DR, Ash AS, Reisman JI, Ozonoff A. Prompt repeat testing after out-of-range INR values: a quality indicator for anticoagulation care. Circ Cardiovasc Qual Outcomes 2011; 4:276-82. [PMID: 21505156 DOI: 10.1161/circoutcomes.110.960096] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved control of oral anticoagulation reduces adverse events. A program of quality measurement is needed for oral anticoagulation. The interval until the next test after an out-of-range International Normalized Ratio (INR) value (the "follow-up interval") could serve as a process of care measure. METHODS AND RESULTS We studied 104 451 patients cared for by 100 anticoagulation clinics in the Veterans Health Administration (VA). For each site, we computed the average follow-up interval after low (≤1.5) or high (≥4.0) INR. Our outcome was each site's average anticoagulation control, measured by percent time in therapeutic range (TTR); 59 837 patients (57%) contributed to the low INR analysis, 37 697 (36%) contributed to the high INR analysis, and all patients contributed to the dependent variable (mean site TTR). After a low INR, site mean follow-up interval ranged from 10 to 24 days. Longer follow-up intervals were associated with worse site-level control (1.04% lower for each additional day, P<0.001). After a high INR, site mean follow-up interval ranged from 6 to 18 days, with longer follow-up intervals associated with worse site-level control (1.12% lower for each additional day, P<0.001). These relationships were somewhat attenuated but still highly statistically significant when the proportion of INR values in-range was used as the dependent variable rather than TTR. CONCLUSIONS Prompt repeat testing after out-of-range INR values is associated with better anticoagulation control at the site level and could be an important part of a quality improvement effort for oral anticoagulation.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Road, Bedford, MA 01730, USA.
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Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Risk-Adjusted Percent Time in Therapeutic Range as a Quality Indicator for Outpatient Oral Anticoagulation. Circ Cardiovasc Qual Outcomes 2011; 4:22-9. [DOI: 10.1161/circoutcomes.110.957738] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Oral anticoagulation is safer and more effective when patients receive high-quality care. However, there have been no prior efforts to measure quality of oral anticoagulation care or to risk adjust it to ensure credible comparisons. Our objective was to profile site performance in the Veterans Health Administration (VA) using risk-adjusted percent time in therapeutic range (TTR).
Methods and Results—
We included 124 551 patients who received outpatient oral anticoagulation from 100 VA sites of care for indications other than valvular heart disease from October 1, 2006, to September 30, 2008. We calculated TTR for each patient and mean TTR for each site of care. Expected TTR was calculated for each patient and each site based on the variables in the risk adjustment model, which included demographics, comorbid conditions, medications, and hospitalizations. Mean TTR for the entire sample was 58%. Site-observed TTR varied from 38% to 69% or from poor to excellent. Site-expected TTR varied from 54% to 62%. Site risk-adjusted performance ranged from 18% below expected to 12% above expected. Risk adjustment did not alter performance rankings for many sites, but for other sites, it made an important difference. For example, the site ranked 27th of 100 before risk adjustment was one of the best (risk-adjusted rank, 7). Risk-adjusted site rankings were consistent from year to year (correlation between years, 0.89).
Conclusions—
Risk-adjusted TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated health system. This measure can serve as the basis for quality measurement and quality improvement efforts.
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Affiliation(s)
- Adam J. Rose
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
| | - Elaine M. Hylek
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
| | - Al Ozonoff
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
| | - Arlene S. Ash
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
| | - Joel I. Reisman
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
| | - Dan R. Berlowitz
- From the Center for Health Quality, Outcomes, and Economic Research (A.J.R., A.O., J.I.R., D.R.B.), Bedford VA Medical Center, Bedford, Mass; Department of Medicine (A.J.R., E.M.H., A.S.A., D.R.B.), Section of General Internal Medicine, Boston University School of Medicine, Boston, Mass; Biostatistics Section (A.O.), Boston Children's Hospital, Boston, Mass; Department of Quantitative Health Sciences (A.S.A.), Division of Biostatistics and Health Services Research, University of Massachusetts School
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Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA). J Thromb Haemost 2010; 8:2182-91. [PMID: 20653840 DOI: 10.1111/j.1538-7836.2010.03996.x] [Citation(s) in RCA: 186] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients receiving oral anticoagulation, improved control can reduce adverse outcomes such as stroke and major hemorrhage. However, little is known about patient-level predictors of anticoagulation control. OBJECTIVES To identify patient-level predictors of oral anticoagulation control in the outpatient setting. PATIENTS/METHODS We studied 124,619 patients who received oral anticoagulation from the Veterans Health Administration from October 2006 to September 2008. The outcome was anticoagulation control, summarized using percentage of time in therapeutic International Normalized Ratio range (TTR). Data were divided into inception (first 6 months of therapy; 39,447 patients) and experienced (any time thereafter; 104,505 patients). Patient-level predictors of TTR were examined by multivariable regression. RESULTS Mean TTRs were 48% for inception management and 61% for experienced management. During inception, important predictors of TTR included hospitalizations (the expected TTR was 7.3% lower for those with two or more hospitalizations than for the non-hospitalized), receipt of more medications (16 or more medications predicted a 4.3% lower than for patients with 0-7 medications), alcohol abuse (-4.6%), cancer (-3.1%), and bipolar disorder (-2.9%). During the experienced period, important predictors of TTR included hospitalizations (four or more hospitalizations predicted 9.4% lower TTR), more medications (16 or more medications predicted 5.1% lower TTR), alcohol abuse (-5.4%), female sex (- 2.9%), cancer (-2.7%), dementia (-2.6%), non-alcohol substance abuse (-2.4%), and chronic liver disease (-2.3%). CONCLUSIONS Some patients receiving oral anticoagulation therapy are more challenging to maintain within the therapeutic range than others. Our findings can be used to identify patients who require closer attention or innovative management strategies to maximize benefit and minimize harm from oral anticoagulation therapy.
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Affiliation(s)
- A J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, MA 01730, USA.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, UK
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Marinigh R, Lip GYH, Lane DA. Stroke prevention in atrial fibrillation patients. Expert Opin Pharmacother 2010; 11:2331-50. [DOI: 10.1517/14656566.2010.498819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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