title: Results of a Regional Effort to Improve Warfarin Management.
abstract: 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.
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.|2 Boston University School of Medicine, MA, USA.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Rose
authors.affiliation: 3 New England Veterans Engineering Resource Center, Boston, MA, USA.
authors.forename: Angela
authors.initials: A
authors.lastname: Park
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Gillespie
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.|4 Boston University School of Public Health, MA, USA.
authors.forename: Carol
authors.initials: C
authors.lastname: Van Deusen Lukas
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.|5 Boston Children's Hospital, MA, USA.|6 Harvard Medical School, Boston, MA, USA.
authors.forename: Al
authors.initials: A
authors.lastname: Ozonoff
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.
authors.forename: Beth Ann
authors.initials: BA
authors.lastname: Petrakis
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.
authors.forename: Joel I
authors.initials: JI
authors.lastname: Reisman
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.|2 Boston University School of Medicine, MA, USA.|4 Boston University School of Public Health, MA, USA.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Borzecki
authors.affiliation: 7 VA Sunshine Healthcare Network, St Petersburg, FL, USA.
authors.forename: Ashley J
authors.initials: AJ
authors.lastname: Benedict
authors.affiliation: 3 New England Veterans Engineering Resource Center, Boston, MA, USA.
authors.forename: William N
authors.initials: WN
authors.lastname: Lukesh
authors.affiliation: 3 New England Veterans Engineering Resource Center, Boston, MA, USA.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Schmoke
authors.affiliation: 8 VA Central Western Massachusetts Healthcare System, Northampton, MA, USA.
authors.forename: Ellen A
authors.initials: EA
authors.lastname: Jones
authors.affiliation: 9 VA Pharmacy Benefits Management Services, San Diego, CA, USA.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Morreale
authors.affiliation: 10 VA Pharmacy Benefits Management Services, Hines, IL, USA.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Ourth
authors.affiliation: 11 Manchester VA Medical Center, NH, USA.
authors.forename: James E
authors.initials: JE
authors.lastname: Schlosser
authors.affiliation: 12 VA New England Healthcare System, Bedford, MA, USA.
authors.forename: Michael F
authors.initials: MF
authors.lastname: Mayo-Smith
authors.affiliation: 13 VA Salt Lake City Healthcare System, UT, USA.
authors.forename: Arthur L
authors.initials: AL
authors.lastname: Allen
authors.affiliation: 14 University of Utah College of Pharmacy, Salt Lake City, UT, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Witt
authors.affiliation: 15 VA Portland Healthcare System, OR, USA.|16 VA Center for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
authors.forename: Christian D
authors.initials: CD
authors.lastname: Helfrich
authors.affiliation: 1 Bedford VA Medical Center, MA, USA.|4 Boston University School of Public Health, MA, USA.
authors.forename: Megan B
authors.initials: MB
authors.lastname: McCullough
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects*; D003695:Delivery of Health Care / Q000592:standards* / Q000639:trends; D006801:Humans; D019934:International Normalized Ratio; D009511:New England; D058996:Quality Improvement; D014481:United States; D014493:United States Department of Veterans Affairs; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: anticoagulants; implementation science; quality of health care; warfarin