title: Warfarin dose management affects INR control.
abstract: BACKGROUND
  Little is known about how patterns of warfarin dose management contribute to percentage time in the therapeutic International Normalized Ratio (INR) range (TTR).
  
  
  OBJECTIVE
  To quantify the contribution of warfarin dose management to TTR and to define an optimal dose management strategy.
  
  
  METHODS
  We enrolled 3961 patients receiving warfarin from 94 community-based clinics. We derived and validated a model for the probability of a warfarin dose change under various conditions. For each patient, we computed an observed minus expected (O - E) score, comparing the number of dose changes predicted by our model to the number of changes observed. We examined the ability of O - E scores to predict TTR, and simulated various dose management strategies in the context of our model.
  
  
  RESULTS
  Patients were observed for a mean of 15.2 months. Patients who deviated the least from the predicted number of dose changes achieved the best INR control (mean TTR 70.1% unadjusted); patients with greater deviations had lower TTR (65.8% and 62.0% for fewer and more dose changes respectively, Bonferroni-adjusted P < 0.05/3 for both comparisons). On average, clinicians in our study changed the dose when the INR was 1.8 or lower/3.2 or higher (mean TTR: 68%); optimal management would have been to change the dose when the INR was 1.7 or lower/3.3 or higher (predicted TTR: 74%).
  
  
  CONCLUSIONS
  Our observational study suggests that INR control could be improved considerably by changing the warfarin dose only when the INR is 1.7 or lower/3.3 or higher. This should be confirmed in a randomized trial.
authors.affiliation: Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA 01730, USA. adamrose@bu.edu
authors.forename: A J
authors.initials: AJ
authors.lastname: Rose
authors.forename: A
authors.initials: A
authors.lastname: Ozonoff
authors.forename: D R
authors.initials: DR
authors.lastname: Berlowitz
authors.forename: L E
authors.initials: LE
authors.lastname: Henault
authors.forename: E M
authors.initials: EM
authors.lastname: Hylek
mesh_terms: D054796:Drug Dosage Calculations; D006801:Humans; D019934:International Normalized Ratio / Q000592:standards*; D008954:Models, Biological; D015233:Models, Statistical; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D014859:Warfarin