title: Computerized clinical decision support improves warfarin management and decreases recurrent venous thromboembolism.
abstract: BACKGROUND
  An explicit approach to warfarin dose adjustment using computerized clinical decision support (CDS) improves warfarin management. We report metrics of quality for warfarin management before and after implementation of CDS in a large health care system.
  
  
  METHODS
  A total of 2591 chronically anticoagulated patients were eligible for inclusion. We compared interpatient time in therapeutic range (TTR) and international normalized ratio (INR) variability before and after implementation of CDS. We report outcomes of major bleeding, thrombosis, and health care utilization.
  
  
  RESULTS
  Implementation of CDS significantly improved TTR (from 63.99% to 65.13%; P = .04) and reduced out-of-range INRs (from 42.39% to 39.97%; P < .001). Venous thromboembolism (relative risk [RR] 0.41; P < .001) emergency department utilization (RR 0.62; P < .001), and hospitalization (RR 0.62; P < .001) were reduced after CDS implementation. Major hemorrhage was more frequent after CDS implementation (RR 1.42; P = .01).
  
  
  CONCLUSIONS
  The CDS warfarin management was associated with improved TTR and decreased INR variability in a large cohort of chronically anticoagulated patients. Clinically relevant outcomes were broadly improved, although more bleeding events were observed.
authors.affiliation: Department of Medicine, Intermountain Medical Center, Murray, UT, USA Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA scott.woller@imail.org.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Woller
authors.affiliation: Department of Medicine, Intermountain Medical Center, Murray, UT, USA Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Stevens
authors.affiliation: Intermountain Healthcare Salt Lake Clinic, Salt Lake City, UT, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Towner
authors.affiliation: Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA.
authors.forename: Jeff
authors.initials: J
authors.lastname: Olson
authors.affiliation: Intermountain Healthcare Salt Lake Clinic, Salt Lake City, UT, USA.
authors.forename: Paige
authors.initials: P
authors.lastname: Christensen
authors.affiliation: Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Sharon
authors.initials: S
authors.lastname: Hamilton
authors.affiliation: Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Laurel
authors.initials: L
authors.lastname: Newman
authors.affiliation: Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Loren
authors.initials: L
authors.lastname: Mott
authors.affiliation: Intermountain Healthcare Homer Warner Center for Medical Informatics, Murray, UT, USA.
authors.forename: Ping
authors.initials: P
authors.lastname: Hu
authors.affiliation: Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: Brunisholz
authors.affiliation: Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA Roseman University of Health Sciences, South Jordan, UT, USA.
authors.forename: Yenh
authors.initials: Y
authors.lastname: Long
authors.affiliation: Medical Informatics, Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Jim
authors.initials: J
authors.lastname: Lloyd
authors.affiliation: Medical Informatics, Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Evans
authors.affiliation: Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: Wayne
authors.initials: W
authors.lastname: Cannon
authors.affiliation: Department of Medicine, Intermountain Medical Center, Murray, UT, USA Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
authors.forename: C Greg
authors.initials: CG
authors.lastname: Elliott
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000097:blood*; D003658:Decision Making, Computer-Assisted; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D054556:Venous Thromboembolism / Q000097:blood* / Q000188:drug therapy*; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: anticoagulants; bleeding; clinical pharmacology; thrombosis