A Successful Performance Improvement Story
Multiple studies1-2 have shown that usual care in physician offices results in only ~ 40-50% of patients anticoagulated with warfarin are "in-range" resulting in risk for thrombosis and bleeding. Inappropriate anticoagulation can occur because the clinician is unaware or unable to implement consensus guidelines for dosing warfarin, poor education of patients regarding drug and diet interactions and patients lost to follow up. Patient morbidity and hospital admissions are the result of suboptimal therapy.9 Multiple studies have demonstrated that well run anticoagulation clinics can improve the "in range" patients to 70-75% with decreased complications. Anticoagulation clinics are an answer but require close coordination between the anticoagulation clinic and the patient's private practice and increased number of employees (e.g., Pharmacists, Nurses,and Secretaries). For many health systems with tight budgets, a management system that can reproduce the value of anticoagulation clinics is needed in physicians offices.
Create a virtual anticoagulation clinic. Develop a secure web based program that allows integrated health systems, individual physician offices or anticoagulation clinics to implement tracking of patients, decision support implementing consensus dosing guidelines and provide standardized reliable educational material. If run in an office, re-engineer the office by assignment of office coordinators (nurse, office assistant or physician) to improve the communication and education of patients. For health systems, create centralized monitoring of performance by individual practices which allows deployment of resources to implement "best practice" across a health system.
Get the patient invested in their own health! Enable on-line patient viewing of clinical flowsheets and reference material to enhance patient compliance. If patients are on home INR monitoring, allow them to enter their own INR values while receiving decision support and then notify clinicians when logging in that their patients have entered INR values.
The Pilot Study:
As a collaborative effort between Physicians, Pharmacists, Nursing and Administration, Abington Physician Network implemented webINR starting in July 2002 enrolling 1323 patients from 29 Internal Medicine and Family Practices. In the first 9 months, (495 patient years of observation) the following were attained.
The early results were obtained without patient on-line access to webINR. To further improve performance, we are currently engaging our patients through the webINR portal and we are studying "best practices" and any potential barriers (computer access, staffing patterns, etc.) amongst the network offices. Admissions for anticoagulation complications and hospital days are under study. Patient satisfaction will be reviewed. Note that Physician and Professional Office Staff satisfaction have been measured and are in the excellent range with the program.
(comparison pre/post implementation)
Complications (per 100 pt - years)
(webINR vs. an anticoagulation clinic 3)
Age and Diagnoses
(distribution in study)
Morbidity & Mortality Data