Results of a Regional Effort to Improve Warfarin Management

Adam J. Rose*, Angela Park, Christopher Gillespie, Carol Van Deusen Lukas, Al Ozonoff, Beth Ann Petrakis, Joel I. Reisman, Ann M. Borzecki, Ashley J. Benedict, William N. Lukesh, Timothy J. Schmoke, Ellen A. Jones, Anthony P. Morreale, Heather L. Ourth, James E. Schlosser, Michael F. Mayo-Smith, Arthur L. Allen, Daniel M. Witt, Christian D. Helfrich, Megan B. McCullough

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: 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. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: 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. Results: 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. Conclusions: 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.

Original languageAmerican English
Pages (from-to)373-379
Number of pages7
JournalAnnals of Pharmacotherapy
Issue number5
StatePublished - 1 May 2017
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2017, © The Author(s) 2017.


  • anticoagulants
  • implementation science
  • quality of health care
  • warfarin


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