Anticoagulation Management

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• Anticoagulation Management
• Addressing Patient Safety In the Ambulatory
  Setting
• Keith Sweigard, MD.
• Chief, I.M. Assoc. Medical Director,
• Abington Memorial Hospital
• President, Prismedic, Inc. - webINR

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Philadelphia Medical UpdateUniversal Sign of
Choking

• Old Sign

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What is Warfarin?

• Definition An oral anticoagulant for short term
  or long term use
• Indications Many Venous and Arterial clotting
  disorders
• Mechanism of Action Vitamin K Antagonist results
  in reduced blood coagulation factors of II, VII,
  IX and X
• Dosing individualized based on Protime / INR
  (International Normalized Ratio) Results
• Interactions
• Drug interactions
• Antibiotics kill bacteria producing Vit K
• Cytochrome system metabolism in the liver
• Affect protein binding of warfarin in the blood
• Diet interactions especially green vegetables
• Complications
• Bleeding (GI, Retroperitoneal, Cerbral)
• Ischemic (Cerebral, Peripheral Vascular,
  Pulmonary emboli)

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Cerebral Complications of Anticoagulation

• Under dosing
• - Ischemia

Over dosing - Hemorrhage
Correct Dosing - Normal
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Why focus Q.I. on warfarin?

• Effective Drug for multiple diagnoses
• Prevalence 1 of population in a Primary Care
  Office
• (10-20 patients per physician at any time)
• Narrow toxic to therapeutic ratio
• Literature demonstrates poor delivery of care for
  Usual Care Model
• Low Cost Tools exist to improve care.

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Clinical Scenario to Study Physician Variance in
Managing Warfarin
You are managing a patient with atrial
fibrillation on warfarin therapy. In the
patients chart there is a table with the
following INRs and warfarin dosing. The patient
denies any change in diet, medications and states
he is compliant on therapy.
1. Please enter the dosing of warfarin that you
would next prescribe in the open blocks of the
table above for the INR performed on
12/18/03. 2. When would you check the next
INR? ______ days or _______ wks or
______ months
Survey AMH, December 2003, K. Sweigard, MD
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Variance - Results of Survey
73 Physicians (13 Cardiologists, 32 Internists
26 Family Physicians, 2 Other )
Guidelines (5- 7 days)
Guidelines (10-15)
Survey AMH, December 2003, K. Sweigard, MD
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Warfarin Management ProtocolAdapted from Chest,
2001 Guidelines, J. Ansel et al.
Guidelines also exist for high intensity 2.5
-3.5 Range
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Abington Memorial HospitalStimulus for
Anticoagulation Improvement Projects

• In patient Anticoagulation project (2000-2001)
• Turned over control of heparin and warfarin to
  pharmacy driven protocols for many Diagnoses
• Improved outcomes (time to effective
  anticoagulation)
• Discovered multiple hospital admissions for
  complications of outpatient anticoagulation with
  warfarin (sentinel events)
• Survey of office practices (27) for Abington
  Physician Network showed wide variance of care
  patterns for education, tracking dosing

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A.P.N. Needs Assessment

• Needed effective low cost deployable intervention
• Available computerized monitoring tools did not
  meet our needs as a physician network
• No extra FTEs available
• Workflow vs. Patient Safety
• Make it scalable to share with others if
  successful
• Assemble Team of Champions
• Physicians (4), Pharmacists (1), Q.A. Nurse (1),
  Network Administrators (2), Information
  Technology Student (1)
• Created webINR 2003 John Eisenberg Patient
  Safety Award for Health Systems Innovation.

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Available Computer Programs for Warfarin
Management

• INR Star (From U.K., runs on Local PCs, fee)
• http//www.anticoagulation.com/INRstar.htm
• Coagclinic (Standing Stone web based, connects to
  POC device, fee)
• http//www.coaguchek-usa.com/information_for_profe
  ssionals/products/patient_software/
• Coumacare (Bristol-Myers Squibb, runs on local
  PC, free, no built in decision support
  guidelines)
• http//www.coumacare.com/
• Coag care (web based, fee)
• http//www.zycare.com/coagcare.htm

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Warfarin Management Computer Software
Meta-analysis of Inpatient and Outpatient Studies
1.58
G. Chatellier, Computer-Adjusted Dosage of
Anticoagulant Therapy Improves the Quality of
Anticoagulation, IMIA, 1998 pp 819-823.
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Re-Engineer Warfarin CareUsing Non Physicians

• Vadher BD, Patterson DL, Leaning M. Comparison
  of oral anticoagulant control by a
  nurse-practitioner using a computer
  decision-support system with that by clinicians.
  Clin Lab Haematol. 1997 Sep19(3)203-7.
• For INRs Goal 2-3 Time in Therapeutic Range
  60.7 nurse/computer vs. 51.6 Resident Doctors
  in clinic.
• Fitzmaurice DA, Hobbs FD, Murray ET. Primary care
  anticoagulant clinic management using
  computerized decision support and near patient
  International Normalized Ratio (INR) testing
  routine data from a practice nurse-led clinic.
  Fam Pract. 1998 Apr15(2)144-6.
• The mean percentage of patients in range 72

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Patient EducationThey control our outcomes!

• Warfarin Education
• Individual Physician Instruction
• Booklet with Core Information on Warfarin
• Percentage of Patients with correct answers in
  yellow
• What is the strength of your warfarin tablets?
  45
• Do you know the indication for your warfarin? 45
• What will you do if you missed a dose? 35
• What will happen with over-anticoagulation? 20
• Correlation of Patients Knowledge and INRs in
  range
• (r.20, p.024)
• Tang EO, Lai CS, Lee KK, Wong RS, Cheng G, Chan
  TY. Relationship between patients' warfarin
  knowledge and anticoagulation control, Ann
  Pharmacother. 2003 Jan37(1)34-9.

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Warfarin Management Models
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Failure Mode Effects Analysis in Outpatient
Warfarin Care Process
Patient Selection
Office Coordinator?
INR Results Available?
clinicians
Standardized Dosing
Effective Tracking of Patients
patients
Standardized Patient Education Regarding
Compliance, Drug Food Interactions
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Live Demonstration

• Login
• Home Page
• Patient Flow Sheet
• Reference Material
• Reports

www.webinr.com
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APN Chemical (INR) OutcomesPre Post webINR
80
9 Month Pilot 1323 Patients 27 Practices, APN,
2002
70
70
60
51
50
Baseline
38
40
webINR
30
22
20
11
8
10
0
Theraputic
Super-therapeutic
Sub-theraputic
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Clinical Outcomes Usual Care vs. Anticoagulation
Clinics
per 100 pt-years
UC Usual Care AC Anticoagulation Clinic
VAC Virtual Anticoagulation Clinic References _at_
www.webinr.com/success.htm
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APN Pilot Study Performance
2002 APN, Nine Month Pilot
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Dispelling the myths

• Education Gaps
• Under dosing prevalent
• 2 x Protime does not INR 2.0
• Diagnoses
• Atrial Fibrillation
• If I use a little it still works and is less
  risky
• Post Op Orthopedic patients (1.5 - 2.0)
• Dogma Thats how they do it down town

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Atrial Fibrillation Effect of Intensity of
Warfarin Therapy
Effect of intensity of oral anticoagulation on
stroke severity and mortality in atrial
fibrillation.Hylek EM, Go AS, Chang Y, Jensvold
NG, Henault LE, Selby JV, Singer DE. , N Engl J
Med. 2003 Sep 11349(11)1019-26.
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Early Adopters of webINR Large Practices
K. Sweigard K. Shields, Abstract, National
Conference on Anticoagulation Therapy, San
Francisco, CA, 2002
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Late Adopters of webINR

• Office Coordinators
• Our physician still wants to manage the warfarin
  so I just put in the values he/she picks
• I do not feel comfortable managing a toxic
  medication
• I didnt know the program could do that!

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Potential Barriers to webINR Implementation

• Physician Supports Program Concept?
• Guidelines Reviewed and Accepted?
• Adequate Staffing?
• Coordinator effective communicator?
• Computer Available with Internet Access
• Adequate Speed?
• Costs who will pay for performance improvement?

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Who will pay for performance?

• Providers
• Do the right thing
• Competitive Pressures Consumer (Patient)
  comparisons
• Insurance Companies
• Cost benefits (Potential Pilot in Southeast PA
  with IBC)
• Competitive Pressures HEDIS Requirement?
• Government
• Do the right thing
• Cost benefits
• Patients?

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Clinician Satisfaction
webINR, APN Survey 2002
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Current Abington Physician Network
Anticoagulation Topics

• Continuity of care fax sheets at time of
  discharge (or entry of patients into webINR
  system in hospital)
• Point of Care Testing Devices
• Implementing Patient Portal
• Atrial Fibrillation Study Query APN Practice
  Management Software to determine if all patients
  eligible are on warfarin?

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Future of Oral AnticoagulationNew Drugs
Ximelegatron?

• Upside
• Standard Dosing,
• No lab monitoring or significant drug
  interactions
• Complication rates similar to warfarin
• Studies to date as effective as warfarin
• (Sportif Trial V Afib)

• Downside
• Liver Function Abnormalities usually low level
  and reversible
• Costs unclear versus warfarin with monitoring
• New Drug unknown side effects, increased cancer
  risk?

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Presentations, Publications Awards

• Partnership Symposium Smart Design for Patient
  Safety, Washington, DC.
• American Hospital Association Quest for Quality
  Abington Memorial Hospital 2003 Award Winner
• Abstract, National Conference on Anticoagulation
  Therapy, San Francisco, CA
• Published article in Health Technology Trends
  May, 2003
• Finalist - VHA Leadership Award in Clinical
  Excellence
• 2003 John Eisenberg Award for Health System
  Innovation
• Delaware Valley Medication Safety Award Runner
  Up

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Goals Objectives

• Understand problems of usual care and variance
  in management of anticoagulation
• Understand how implementation of guidelines,
  re-engineering care providers and use of
  technology can effectively implement performance
  improvement
• Understand barriers when implementing performance
  improvement for anticoagulation.
• Inspire other Hospitals and Health Systems to
  create innovative solutions for health care
  processes

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webINR Screenshots
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