Rose Adam J, Park Angela, Gillespie Christopher, Van Deusen Lukas Carol, Ozonoff Al, Petrakis Beth Ann, Reisman Joel I, Borzecki Ann M, Benedict Ashley J, Lukesh William N, Schmoke Timothy J, Jones Ellen A, Morreale Anthony P, Ourth Heather L, Schlosser James E, Mayo-Smith Michael F, Allen Arthur L, Witt Daniel M, Helfrich Christian D, McCullough Megan B
1 Bedford VA Medical Center, MA, USA.
2 Boston University School of Medicine, MA, USA.
Ann Pharmacother. 2017 May;51(5):373-379. doi: 10.1177/1060028016681030. Epub 2016 Dec 17.
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.
To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA).
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.
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.
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.
华法林抗凝控制的改善可减少不良事件，是质量改进的一个目标。此前尚无研究描述过在整个医疗系统中改善抗凝控制的努力。
描述退伍军人健康管理局（VA）新英格兰地区改善抗凝控制工作的结果。
我们的干预措施涵盖了新英格兰地区（退伍军人综合服务网络1 [VISN 1]）管理5000多名患者华法林治疗的8个VA站点。我们为各站点提供了一个护理流程测量系统，以及有针对性的审核和反馈。我们关注与站点层面抗凝控制相关的护理流程，包括国际标准化比值（INR）超出范围后的及时随访、尽量减少失访以及使用符合指南的INR目标范围。我们使用差异中的差异（DID）模型来检查抗凝控制的变化，以治疗范围内时间百分比（TTR）来衡量，以及护理流程指标，并将VISN 1站点与位于VISN 1之外的116个VA站点进行比较。
VISN 1站点的TTR（我们的主要质量指标）从66.4%提高到69.2%，而VISN 1之外的站点从65.9%提高到66.4%（DID为2.3%，P < 0.001）。TTR的改善与护理流程指标的改善程度密切相关，而这些指标在VISN 1各站点之间差异很大。
一项区域质量改进计划，通过绩效测量以及审核和反馈，使TTR比对照站点多提高了2.3%，这是一个具有临床重要意义的差异。改善相关护理流程可改善接受华法林治疗患者的预后。
