title: A before and after study of warfarin monitoring in a single region as part of the Scottish patient safety programme in primary care.
abstract: BACKGROUND
  Warfarin is an effective drug for patients at risk of thromboembolic events, but sub-optimal pharmacological management may cause significant harm. As part of the Scottish patient safety programme in primary care, one health board region aimed to determine if the international normalised ratio control for patients taking warfarin in general practice improved over the first 12 months of participation.
  
  
  METHODS
  A before and after study of a multi-intervention improvement strategy was employed that combined financial incentivisation, a regional learning collaborative, clinical care bundle implementation, audit and feedback and clinical 'safety champions'. The main patient outcome measures were: mean time in therapeutic range; proportion with good control (time in therapeutic range >60%) and excellent control (time in therapeutic range > 75%); and the proportion of very abnormal results (international normalised ratio < 1.5 or >5). Chi-square tests were used to determine statistical differences.
  
  
  RESULTS
  In total, 49 of 55 general practices participated (89%) with 33/55 providing usable data (60%) on 1480 patients (before) and 1946 patients (after), respectively. Improvements were observed in mean time in therapeutic range (P < 0.05) as well as in the proportion of patients with good control (time in therapeutic range > 60%, P < 0.01) and excellent control (time in therapeutic range > 75%, P = 0.06). A reduction in the proportion of very abnormal results (international normalised ratio < 1.5 or >5) was also observed (P < 0.01), while the mean number of patient attendances reduced (P < 0.05).
  
  
  CONCLUSIONS
  The introduction of a complex safety improvement intervention via a national patient safety programme has resulted in modest improvements in the control of warfarin monitoring in a single region. These improvements may potentially reduce the incidence of serious adverse events. The study method, interventions and findings should be of interest to primary care settings with similar warfarin management arrangements internationally.
authors.affiliation: Medical Directorate, NHS Education for Scotland, UK GP/Patient Safety Clinical Lead, NHS Ayrshire and Arran, UK Duncan.mcnab@nes.scot.nhs.uk.
authors.forename: Duncan
authors.initials: D
authors.lastname: McNab
authors.affiliation: Medical Directorate, NHS Education for Scotland, UK.
authors.forename: John
authors.initials: J
authors.lastname: McKay
authors.affiliation: Medical Directorate, NHS Education for Scotland, UK Institute of Health and Wellbeing, University of Glasgow, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Bowie
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001291:Attitude of Health Personnel; D058006:General Practice / Q000592:standards*; D006801:Humans; D019934:International Normalized Ratio; D008490:Medical Informatics; D008991:Monitoring, Physiologic; D017063:Outcome Assessment, Health Care; D061214:Patient Safety; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D015397:Program Evaluation; D012606:Scotland / Q000453:epidemiology; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Warfarin; clinical audit; patient safety; primary care; quality improvement