Improving the Management of Warfarin May Be Easier Than We Think

Rose, Adam J.

doi:10.1161/circulationaha.112.141887

Cited by 12 publications

(23 citation statements)

References 14 publications

(14 reference statements)

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“…Our results support the findings of a number of other studies that show that a key factor in good anticoagulant control is adherence to a dosing algorithm 6. In our series, we developed a computerised algorithm which specifically adjusts parameters for individual patients and has enabled clinicians to achieve a high level of control with a TTR of over 75%.…”

Section: Adherence To the Dosing Algorithm And Protocolsupporting

confidence: 86%

An audit of anticoagulant management to assess anticoagulant control using decision support software

Harper

Harper²,

Hill³

2014

BMJ Open

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ObjectiveTo evaluate the effectiveness of a computerised self-adjusting anticoagulant algorithm to predict appropriate warfarin dosing and to assess its use in clinical practice.DesignA 3-year audit of anticoagulant control in patients managed by doctors and pharmacists using computer decision support and an evaluation of the impact of dose adjustments made by the users.Participants3660 patients on oral anticoagulants; one-third of patients managed by doctors and two-thirds by pharmacists.SettingAnticoagulant supervision in primary care and pharmacies at 60 sites in New Zealand.Main outcome measuresThe time in the therapeutic range (TTR), the outcome of adherence to the computer dosing algorithm, the percentage of time the clinicians over-ride the algorithm and the impact of their intervention on anticoagulant control.ResultsA TTR of 72.9% was achieved for all patients. The TTR was significantly better in patients managed by pharmacists than doctors (75.1% versus 67.4%, p<0.0001). The computer algorithm provides appropriate dose recommendations for INR results from 1.5 to 4. Users administered a dose that differed from the computer recommendation 23.3% of the time. The doctors adjusted the dose more frequently (28.2% versus 21.1% of tests) and made larger dose changes than the pharmacists.ConclusionsThe clinicians predominantly change the dose when the INR is below the therapeutic range. The changes are not necessary to correct for inaccuracies in the algorithm. The most likely explanation is the clinician's belief that their own dose adjustment would achieve better control; however, in practice, their changes tend to underdose patients. The doctors achieved poorer control than the pharmacists; this is in part due to the action of the doctors over-riding the algorithm. Our results imply that clinicians could achieve better anticoagulant control if they more closely followed the computer algorithm.

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Section: Adherence To the Dosing Algorithm And Protocolsupporting

confidence: 86%

An audit of anticoagulant management to assess anticoagulant control using decision support software

Harper

Harper²,

Hill³

2014

BMJ Open

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show abstract

“…Many different approaches have been deployed to improve anticoagulation control in patients on warfarin therapy including the deployment of specialized anticoagulation clinics for routine monitoring, the introduction of computerized dosing software programs and dosing algorithms to improve the accuracy of dosing, and the introduction of education programs to improve patient adherence with therapy [6]. However, these measures have been variably implemented in clinical practice.…”

Section: Pharmacology Of Warfarinmentioning

confidence: 99%

Oral anticoagulation: a critique of recent advances and controversies

Pirmohamed

Kamali

Daly

et al. 2015

Trends in Pharmacological Sciences

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“…11 Secondary measures evaluated general quality of warfarin management, including: the percentage of residents receiving at least monthly INR monitoring, TTR (Rosendaal), mean INR, mean time between INRs, proportion of values between 2.3 and 2.7, and the frequency of "excursions" (i.e., INR ≤ 1.5 or ≥ 4.5). 12, 13 Secondary measures applied to all warfarin users, regardless of exposure to interacting antibiotics. Primary and secondary measures were analyzed in aggregate across all participating facilities, with facility-level analysis also being performed.…”

Section: Methods Recruitmentmentioning

confidence: 99%