Improving Anticoagulation Control in VISN 1

Edith Nourse Rogers Memorial Veterans Hospital, Bedford MA

Investigators

Abstract

DESCRIPTION (provided by applicant): Background: Over 100,000 VA patients receive oral anticoagulation (AC) each year to prevent blood clots, including strokes. AC is safer and more effective when it is managed skillfully and therefore well-controlled. AC control can be measured using percent time in therapeutic range (TTR), the proportion of time when patients are sufficiently anticoagulated to prevent clots but not excessively anticoagulated (which increases the risk of bleeding). We have shown that the anticoagulation clinics (ACCs) of the VA vary widely on TTR, from 40% (very poor control) to 70% (excellent control). Improving TTR in the VA would prevent thousands of adverse events, including strokes, major hemorrhages, and deaths. We have further investigated the structures and processes of care that contribute to these wide disparities in TTR performance. Objectives: In this proposed study, we will apply proven methods to change provider behavior and improve patient adherence and self-management. The goal will be to facilitate the adoption of these evidence-based practices in order to improve TTR in VISN 1. We will accomplish this through a two-part intervention: 1) Our clinician-focused intervention will utilize educational outreach, audt and feedback, internal facilitation, and external facilitation to promote improvements in four evidence-based processes of care. 2) Our patient- focused intervention will utilize outreach, a group educational seminar, and motivational interviewing to educate patients with poor baseline anticoagulation control and promote behavior change. Methods: Our clinician-focused intervention will use a Dashboard to measure site-level TTR and processes of care and an Algorithm for routine AC management. Both the Dashboard and the Algorithm are concrete representations of our main evidence-based recommendations to improve AC management. We will promote their use through quarterly visits to the sites, at which we will deliver audit and feedback and educational outreach, and also provide external facilitation to address ways to improve these performance measures. Our patient-level intervention will be delivered to the 25% of VISN patients with low TTR at baseline (<50%). ACC staff will identify such patients using the Dashboard, and will send them an outreach letter inviting them to attend a brief educational seminar. All intervention patients, whether or not they attended the seminar, will receive follow-up management including motivational interviewing (MI) to address behavior change. Our outcome for Aim 1 is change in site TTR over time, which will be compared between VISN 1 and non-VISN 1 sites using an interrupted time series. Our outcome for Aim 2 is change in patient-level TTR, for which intervention and control patients will be compared using a regression discontinuity analysis. Secondary outcomes will include site-level changes in processes of anticoagulation care (measured using automated data), costs and cost savings, and sustainability of changes over time. Anticipated Impacts: Through this project, we anticipate that TTR in VISN 1 will increase to 75%, far higher than any other VISN. Such improvement in TTR is associated with greatly reduced rates of adverse events for patients. We also anticipate that improved TTR will save more money than our intervention will cost, in large part because of efficiencies of management and less-frequent follow-up for better controlled patients. At the conclusion of this regional project, we will promote the spread of these interventions throughout the VHA. We anticipate great interest in implementing a program which improves patient outcomes while saving money. PUBLIC HEALTH RELEVANCE: Over 100,000 VHA patients receive anticoagulants (blood thinners) each year to prevent blood clots (including strokes). Too much anticoagulation increases the risk of serious or even fatal bleeding, and too little anticoagulation fails to protect the patient against blood clots. VHA anticoagulation clinics vary widely on how much time their patients spend in the therapeutic range, the range within which they are protected from clots but not at excessive risk of bleeding. Anticoagulation clinics can improve anticoagulation control by following several relatively simple procedures, including following-up promptly when patients are out of range and focusing on educating and supporting patients with poor control. In this study, we will promote these practices at the anticoagulation clinics of the New England VA region, with a goal of improving anticoagulation control.