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Continuous Quality Improvement Network Project #3
Appropriate Treatment for ESTABLISHED Patients on Warfarin for One or More of the Following Three Conditions

1. Chronic or Paroxysmal Atrial Fibrillation
2. Prosthetic Valve
3. Diagnosed Deep Vein Thrombosis or Pulmonary Embolism

Click here for PDF version of this document.

Contents:

Explanation of importance of condition (why chosen)
Rationale for criteria/quality indicators and supporting scientific evidence
Class of patients to be monitored
Instructions for completion of the condition template
Scope of the template
References
Bibliography

Explanation of importance of condition (why chosen)

• Anticoagulation with warfarin represents a risk to the patient, with under-anticoagulation the risk of clotting, with over-anticoagulation the risk of bleeding. For these reasons, internists must systematically monitor those patients whom they have selected for anticoagulation therapy.

  The most common indication for anticoagulation in internal medicine is atrial fibrillation. The prevalence of atrial fibrillation among individuals over age 65 approaches 5% and increases with age. The relationship of atrial fibrillation, whether rheumatic or non-rheumatic in etiology, to stroke is well established. Several practice guidelines regarding anticoagulation management of atrial fibrillation are available (1). Other indications for the use of anticoagulation therapy include deep vein thrombosis/pulmonary embolism and prosthetic valve implants.

  Despite the demonstrated safety and efficacy of oral anticoagulation therapy, it is still underused for certain conditions. One of the major barriers is concern about the difficulty of managing patients taking anticoagulation therapy. The management of oral anticoagulation is a labor-intensive process involving frequent patient-practitioner encounters and international normalized ratio (INR) measurements to achieve desirable clinical outcomes. Additionally, anticoagulation therapy requires interaction among patients, physicians, and other healthcare practitioners regarding laboratory values, start and stop dates of other concomitant medication, need for patient education, and review of patient variables to make the appropriate therapy adjustments(1). Based upon a growing foundation of evidence in the healthcare literature and on the experience of many practitioners, a systematic and coordinated approach to the management of oral anticoagulation provides for better clinical outcomes than a less-structured approach. Systematic outpatient anticoagulation management services, designed to coordinate and optimize the delivery of anticoagulation therapy, not only improve the safety and effectiveness of the therapy but ease the burden on the primary care practitioner (1).

Rationale for criteria/quality indicators and supporting scientific evidence

• Certain principles should govern anticoagulation therapy:

  • The INR is the best laboratory monitor for warfarin anticoagulation.
  • The optimal interval for monitoring warfarin therapy should not exceed 6 weeks.
  • Patients should be educated regarding the benefits and risks of anticoagulation therapy.
  • Patients should be educated regarding drug and food interactions with warfarin.
  • Physician offices should have a policy regarding anticoagulation:
    1. criteria for refilling warfarin prescriptions;
    2. responses to noncompliance with INR monitoring;
    3. responses to critically low and high INR values; and
    4. alerts for prescribing of other medications, especially sulfonamide antibiotics.

Class of patients to be monitored

• The patient population to be monitored comprises those individuals in an internal medicine outpatient practice receiving warfarin for anticoagulation for the diagnoses of atrial fibrillation, both valvular and nonvalvular; prosthetic valve implants; pulmonary embolism; or deep vein thrombosis.

Instructions for completion of the condition template

1. Brief your staff on the reasons for your participation in this quality improvement project and acknowledge their important role in the successful completion of the project.
2. Identify 25 patients who are receiving warfarin for anticoagulation for one of the following diagnoses: chronic or paroxysmal atrial fibrillation, both valvular and non-valvular; prosthetic valve implants; pulmonary embolism; or deep vein thrombosis.
   
   

3. • NOTE. Only identify charts of patients whom you have continuously managed for the past 12 months and are currently on warfarin. Fill in before or at time of office visit

4. Follow the instructions on the Warfarin Template for data abstraction.

Scope of the template

• The purpose of this template is to monitor:

  1. The presence of an anticoagulation flowsheet.
  2. The recording of an indication for anticoagulation.
  3. The advance determination of duration of anticoagulation.
  4. The recording of the desired INR range.
  5. Patient and/or caretaker education.
  6. The frequency of INR monitoring.

• The instrument focuses only on patients identified as receiving warfarin, not on those patients for whom indicated anticoagulation has been omitted.

  At the onset of warfarin therapy, these determinations should have been established:

  • The indication for anticoagulation. (Question 5)
  • The duration of anticoagulation. (Question 6)
  • The expected INR range. (Question 7)

• Each patient receiving warfarin should be able to identify: (Questions 8 and 9)

  • The risks and benefits of anticoagulation therapy and the reasons for taking warfarin.
  • Diet, drug, and alcohol use that might cause problems with therapy.
  • The need to make necessary lifestyle changes.
  • Common signs of bleeding.
  • What to do in case of an emergency.

References

• (1) Ansell JE, Buttaro ML, Thomas OV, Knowlton CH, et al. Consensus guidelines for coordinated outpatient oral anticoagulation therapy management. Ann Pharmacother. 1997;31:604-615.

Bibliography

• Hirsh J, Dalen JE, Deykin D, Poller L, Bussey H. Oral anticoagulants: Mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest. 1995;108(Suppl 4):231-246.

  Laupacis A, Albers G, Dalen J, Dunn M, Feinburg W, Jacobson A. Antithrombotic therapy in atrial fibrillation: Fourth ACCP consensus conference on antithrombotic therapy. Chest. 1995; 108(Suppl 4):352S-359S.

  Prystowski EN, Benson W, Fuster V, Hart RG, Kay GN, Myerburg RJ, et al. Management of patients with atrial fibrillation: A statement for health care professionals from the subcommittee on electrocardiography and electrophysiology. Circulation. 1996;93:1262-1277.

  The Center for Clinical Quality Evaluation. Ambulatory care stroke prevention and treatment initiative: Management of atrial fibrillation: Final report. Washington, DC. 1997.

  Vissing R. Anticoagulation clinic cuts warfarin toxicity rate. QI/TQM. 1997;(April):54-58.

  Weibert RT, Le DT, Kayser SR, Rapaport SI. Correction of excessive anticoagulation with low-dose oral vitamin K1. Ann Intern Med. 1997;126:959-962.

  Williams JR. Reengineering practices for oral anticoagulation monitoring: Health care innovations. Journal of the Association of Managed Healthcare Organizations. 1997;7(2):19-25.

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