Warfarin: Misperceptions lead to underutilization
Warfarin: Misperceptions lead to underutilization
CT group creates stroke prevention program
When the Connecticut Peer Review Organi-zation (CPRO) in Middletown ran its statewide record review of 770,000 Medicare hospitalizations in 1994, it revealed that only 37% of eligible patients were on warfarin at hospital admission. Only half were on warfarin at hospital discharge. Charles B. Seelig, MD, MS, director of medical education at Greenwich (CT) Hospital, acted on the audit immediately.
"The information showed us what we weren’t doing," says Seelig. "What we wanted to know was why we weren’t doing it." Greenwich’s quality team created a successful stroke prevention program that is serving as a model at the state as well as the national level. Its clinical guidelines, care maps, and physician reminder system have improved and standardized the hospital’s atrial fibrillation (AF) care. Chaired by Seelig, the team includes two cardiologists, a neurologist, several internists, nurses, representatives from telemetry and intensive care, pharmacists, and a nurse educator.
A chart audit of all appropriate AF patients discharged August through September last year showed a 61% use of anticoagulation therapy, compared with 42% during the same period of the previous year.
One of the keys to Greenwich’s 43% improvement is that in addition to continuing the chart abstraction work begun by CPRO, the quality team also developed an anonymous questionnaire to measure physicians’ attitudes, knowledge, and perceived barriers toward anticoagulation.
"We discovered their knowledge base was excellent," Seelig says. "What was happening was an issue of perception. They believed they were anticoagulating more frequently than they actually were." The results of the questionnaire showed physicians reported they used warfarin for 80% of the appropriate patients, when the chart abstraction data showed only 40%. It also compared the attitudes of physicians who were high users with those who used the therapy less frequently. They were surprised to find no differences, Seelig says.
The team did find a large difference between risk taking behavior on the part of the physicians who used less anticoagulation therapy. "To a greater degree [than the physicians who used the therapy more often], they felt that risk of the drug was not outweighed by benefits," explains Seelig. "We felt this was the crux of the issue: Some physicians take longer in accepting risky interventions than others." (See chart of risk factors for bleeding, p. 32.)
Examine the whole issue
After compiling questionnaire results, the team decided that to affect the larger issue of AF patient management practices, it would have to consider the big picture. "We designed a care map that looked at the whole process of AF, rather than therapy alone," Seelig says.
The team also created a risk assessment sheet that helps physicians determine whether or not warfarin will be used. "We knew from the survey results that they needed a mechanism to determine risk," he says. The sheet serves as a catalyst to remind and encourage physicians to make a decision as to whether or not to use anticoagulates.
Next, they educated physicians and nurses on the new approach. "We used both formal and informal means," Seelig says. "We discussed it during grand rounds with the physicians, through informal conferences with the residents, as well as in an inservice for nurses on all floors where patients with atrial fibrillation are likely to be admitted."
"It’s important in this type of initiative that physicians do the presentations for other physicians because they can present it in a way that is not threatening," says Gail Doria, MPA, RN, director of quality management at Greenwich.
Martha J. Radford, MD, clinical coordinator for the CPRO, agrees. "Anticoagulating for stroke prevention is a physician decision, so the physician community must be involved with it." For quality improvement professionals, that means incorporating this collaboration into the design of the project from the beginning.
"It is a good way to introduce sometimes reluctant physicians to quality, particularly if you can help with logistical things such as data gathering," Radford adds.
The team avoided reinventing the wheel. Rather than spend time developing handouts for the physician and patient education program, the team used materials from DuPont Merck in Wilmington, DE, the manufacturer of Coumadin. They knew the company would have excellent materials.
The team has also recently completed a follow-up physician survey to determine how perceptions are changing. "We want to find out what is and isn’t working," Seelig says.
Warfarin (DuPont Merck’s Coumadin) is an anticoagulant that prevents up to 80% of strokes in individuals with AF or arrhythmia. And yet the agent is underused. Of the 20% of strokes caused by AF, warfarin anticoagulation in carefully chosen patients can reduce the risk of stroke by up to 68%, says Radford. A recent study out of Yale University supported that statement.1 Researchers found that only 38% or 272 patients with AF received warfarin. "We have a medication that has been shown to be highly effective, but we found that the medical community is not getting this therapy to all the patients who need it," Lawrence M. Brass, MD, a Yale neurologist and one of the investigators said in a statement.
Reference
1. Brass LM, Krumholz HM, Scinto JM, et al. Warfarin use among patients with atrial fibrillation. Stroke 1997; 28:2,382-2,389.
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