Barriers and facilitators to reducing frequent laboratory testing for patients who are stable on warfarin: a mixed methods study of de-implementation in five anticoagulation clinics

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.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0620-x) contains supplementary material, which is available to authorized users.

Assessing the Implementation of Pharmacogenomic Panel-Testing in Primary Care in the Netherlands Utilizing a Theoretical Framework

“…Determinant frameworks, specifically, are used to identify barriers and enablers of implementation [40]. To date, a number of empirical studies used the TICD and other theoretical frameworks to explore implementation issues across therapeutic areas, including lower back pain [41,42], hand hygiene [43], blood transfusion [44], medication prescribing [45], laboratory testing [46], polypharmacy [47], evidence-based recommendations for chronic conditions [48] and primary care [49], schizophrenia [50] and dementia [51]. In general, uncertainty about how to choose interventions that best match implementation determinants in a given context have been reported [52].…”

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

“…The steps include creating conditions for change, engaging in sense‐making conversations with care teams and allowing them to take a sense of ownership of the issue to make their own decision about where the balance of benefit and harm lies. Finally, several studies have adapted the Theoretical Domains Framework to guide or interpret de‐implementation findings . The Theoretical Domains Framework synthesizes psychological theories of behaviour change to help develop theoretically grounded behaviour‐change interventions.…”

International normalised ratio monitoring in the community populations of the Auckland and Northland regions of New Zealand: time in therapeutic range and frequency of testing

“…However, these recommendations have changed, and though NZ best practice guidelines at present recommend testing no less often than every 6–8 weeks, evidence is accumulating that testing selected patients as infrequently as every 12 weeks is safe and feasible . Outside of clinical trials, however, extended intervals have yet not been widely adopted . Consequently, we have concerns that patients in our region are having inappropriate blood tests, with antecedent risks and misallocation of resources.…”

“…Possible methods for improving the appropriate interval of monitoring include provider education, and the use of electronic aids to identify patients where monitoring periods can be lengthened. The expenditure associated with these interventions may be balanced by savings in tests and clinician time; in our cohort, for example, shifting the group of patients with 100% TTR to monitoring every 12 weeks, rather than every 4 weeks, at a cost of NZ$12.2 per INR, would save NZ$107 000 per year, in direct test costs alone.…”

“…3,[18][19][20] Outside of clinical trials, however, extended intervals have yet not been widely adopted. 21 Consequently, we have concerns that patients in our region are having inappropriate blood tests, with antecedent risks and misallocation of resources. Possible methods for improving the appropriate interval of monitoring include provider education, and the use of electronic aids to identify patients where monitoring periods can be lengthened.…”