Abstract
Background Warfarin's adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients. Objectives We sought to describe a health system's chronic warfarin quality metrics in older inpatients, defined by international normalized ratio (INR) control, explore associations between INR overshoots and clinical outcomes, and identify factors associated with overshoots. Patients/Methods Data on patients 65 years and older who were prescribed chronic warfarin and admitted during January 1, 2014, to June 30, 2016, were extracted through retrospective chart review. We defined overshoots as INRs 5 or greater after 48 hours of hospitalization. Logistic regression modeling was used to determine risks for overshoots and multivariate analysis for overshoots' association with length of stay (LOS), bleeding, and mortality. Results Of the 12,107 older inpatients on chronic warfarin, most were 75 years or older (75.7%), female (51.2%), and white (70.0%). While 1,333 (11.0%) of patients had overshoots during the admission, 449 (33.7%) of these reached overshoots after 48 hours. When stratified by overshoots versus no overshoots, LOS more than doubled (15.6 vs. 6.8 days) and the bleed rate was significantly higher (27.4 vs. 8.3%) in the overshoot group. While overall mortality was small (0.4%), the overshoot group's mortality was significantly higher (3.12 vs. 0.28%). Black race and weight were protective against overshoots; history of heart failure and antibiotic/amiodarone exposure were predictive of overshoots. Conclusion This is the largest study examining warfarin quality metrics for hospitalized adults, specifically older inpatients. Our model may serve as the basis for identifying high-risk warfarin patients to target interventions to reduce adverse drug events.
Highlights
The Agency for Healthcare Research and Quality (AHRQ) labels anticoagulants such as warfarin a high-risk drug
This study aims to (1) describe a large health system’s warfarin quality metrics in older inpatients, defined by the international normalized ratio (INR) control, (2) explore the association between inpatient INR overshoots and clinical outcomes, and (3) identify intrinsic and extrinsic patient factors associated with INR overshoots
Patients with INR overshoots were more likely to be discharged without warfarin than those without overshoots (24.3 vs. 7.8%, p < 0.0001). ►Table 1 describes the characteristics of patients on chronic warfarin during their acute hospitalization
Summary
The Agency for Healthcare Research and Quality (AHRQ) labels anticoagulants such as warfarin a high-risk drug. Prior studies have shown that the majority of warfarin-associated bleeds result in serious outcomes, with fatal outcomes reported in up to 10%.1. Warfarin’s adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients
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