Abstract
BackgroundPatients on chronic warfarin therapy require regular laboratory monitoring to safely manage warfarin. Recent studies have challenged the need for routine monthly blood draws in the most stable warfarin-treated patients, suggesting the safety of less frequent laboratory testing (up to every 12 weeks). De-implementation efforts aim to reduce the use of low-value clinical practices. To explore barriers and facilitators of a de-implementation effort to reduce the use of frequent laboratory tests for patients with stable warfarin management in nurse/pharmacist-run anticoagulation clinics, we performed a mixed-methods study conducted within a state-wide collaborative quality improvement collaborative.MethodsUsing a mixed-methods approach, we conducted post-implementation semi-structured interviews with a total of eight anticoagulation nurse or pharmacist staff members at five participating clinic sites to assess barriers and facilitators to de-implementing frequent international normalized ratio (INR) laboratory testing among patients with stable warfarin control. Interview guides were based on the Tailored Implementation for Chronic Disease (TICD) framework. Informed by interview themes, a survey was developed and administered to all anticoagulation clinical staff (n = 62) about their self-reported utilization of less frequent INR testing and specific barriers to de-implementing the standard (more frequent) INR testing practice.ResultsFrom the interviews, four themes emerged congruent with TICD domains: (1) staff overestimating their actual use of less frequent INR testing (individual health professional factors), (2) barriers to appropriate patient engagement (incentives and resources), (3) broad support for an electronic medical record flag to identify potentially eligible patients (incentives and resources), and (4) the importance of personalized nurse/pharmacist feedback (individual health professional factors). In the survey (65% response rate), staff report offering less frequent INR testing to 56% (46–66%) of eligible patients. Most survey responders (n = 24; 60%) agreed that an eligibility flag in the electronic medical record would be very helpful. Twenty-four (60%) respondents agreed that periodic, personalized feedback on use of less frequent INR testing would also be helpful.ConclusionsLeveraging information system notifications, reducing additional work load burden for participating patients and providers, and providing personalized feedback are strategies that may improve adoption and utilization new policies in anticoagulation clinics that focus on de-implementation.
Highlights
Patients on chronic warfarin therapy require regular laboratory monitoring to safely manage warfarin
Leveraging information system notifications, reducing additional work load burden for participating patients and providers, and providing personalized feedback are strategies that may improve adoption and utilization new policies in anticoagulation clinics that focus on de-implementation
All interviewees reported being highly compliant with offering less frequent international normalized ratio (INR) testing to eligible patients. They were surprised to hear that the actual overall utilization rates of less frequent INR testing for eligible patients were closer to 50–60% and not 80–100%, which they had predicted based on their own experience and belief about practice patterns
Summary
Patients on chronic warfarin therapy require regular laboratory monitoring to safely manage warfarin. To explore barriers and facilitators of a de-implementation effort to reduce the use of frequent laboratory tests for patients with stable warfarin management in nurse/pharmacist-run anticoagulation clinics, we performed a mixed-methods study conducted within a state-wide collaborative quality improvement collaborative. After an initial period of frequent dose titration, many patients achieve a relative “steady state” where their warfarin dose does not fluctuate significantly [1] Most of these patients still received a INR blood draw at least every 4 weeks [2]. After extensive discussion at collaborative-wide quarterly meetings, individual anticoagulation clinics developed eligibility criteria for less frequent INR testing (Table 1). These criteria determined the number of INR tests that must be within the target range before a scheduled INR test could be extended beyond the traditional 4-week window. Based on these site-specific criteria, reporting tools were developed to provide real-time feedback to anticoagulation clinic staff
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