title: Effectiveness of a computerized decision support system for anticoagulation management in hemodialysis patients: A before-after study.
abstract: Introduction The risk-benefit profile for warfarin anticoagulation in hemodialysis (HD) patients differs compared with the non-HD population. HD patients are at increased risk of both thromboembolism and bleeding related to anticoagulation therapy. In addition, anticoagulation control may be more difficult to achieve in the HD population due to frequent comorbidities, subclinical Vitamin K deficiency, altered pharmacokinetics due to uremia and the concurrent use of multiple medications. While computerized decision support systems (CDSS) to assist with anticoagulation management are safe and effective in the non-HD population, they have not been well studied in HD outpatients. Methods A before-after study compared anticoagulation control for HD outpatients receiving warfarin at a tertiary medical center in Canada during two time periods: an initial period of nephrologist-led anticoagulation management and a second period after implementation of a pharmacist-led, CDSS-assisted anticoagulation management strategy. Findings Forty-two patients were included. Following implementation of the CDSS-assisted strategy, there was no significant change in median therapeutic time-in-range (3.7% difference (IQR, -9.5% to 20.6%); P = 0.247). Median change in INR testing frequency was 1.2 (IQR, 0.1-2.2; P = 0.0001) fewer tests per patient per month, which equates to approximately 15 fewer tests per patient per year. Adverse events were similar. Discussion Implementing a CDSS-assisted strategy for anticoagulation management in HD outpatients is effective. Doing so may lead to modest cost savings related to less frequent INR testing.
authors.affiliation: Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada. edclark@toh.on.ca.
authors.forename: Edward G
authors.initials: EG
authors.lastname: Clark
authors.affiliation: Division of Hematology, Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Rodger
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Tim O
authors.initials: TO
authors.lastname: Ramsay
authors.affiliation: Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Greg A
authors.initials: GA
authors.lastname: Knoll
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000502:physiology*; D065187:Controlled Before-After Studies / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants
keywords: Warfarin; computer-assisted decision making; computer-assisted drug therapy; drug monitoring; hemodialysis