Anticoagulation CQI

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Anticoagulation CQI

• Escher Howard-Williams
• April 23, 2008

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Overview

• AC, why were lucky to have one
• Patient safety and cost
• What is CQI and how to implement PDSA
• My project through AC addressing health care
  literacy
• Plans for the future (graciously accept
  suggestions)

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Why Anticoagulation clinic (AC)

• Warfarin, is one of the most commonly prescribed
  medications
• Successful anticoagulant management requires
• Careful monitoring of the INR
• Ongoing patient education
• Good communication between patients and their
  caregivers

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Benefits of ACs

• Given warfarins narrow therapeutic index, the
  quality of care influences the risk of patients
  having undesirable outcomes
• Failure to reach the target INR increases the
  risk of thromboembolic complications
• Prolongation of the INR beyond the target range
  increases the risk of major bleeding
  complications including intracranial hemorrhage

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AC Benefits - Patient

• Three RCTs directly comparing ACs to SC concluded
  that
• adverse events (thromboembolism and major
  hemorrhage) were significantly reduced with ACs.
• anticoagulant levels within the therapeutic range
  for a significantly longer time, representing
  better control
• significant cost reduction (gt160,000 per patient
  per 100 patient-years) and decreased emergency
  department (ED) visits

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Overall ACs

• Data seems to indicate that ACs keep our
  patients safer while on warfarin
• TTR is increased
• Decrease adverse events occur including
  thromboembolic and bleeding
• Patient time (travel time in clinic etc.) is
  actually reduced as we will see this effect costs

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AC Benefit - Financial

• Overall cost savings of over 162,000 achieved by
  using AC.
• Anticoagulation-related ED visits decreased from
  22 to 6 per 100 patient-years in the AC cohorts.
• hospitalized 3.22 days and .048 days per
  patient-treatment-year
• net savings in reduced hospitalization costs per
  year in the treatment group was 211776.
• benefitcost ratio (BC) was 6.55, suggesting the
  program is socially valuable

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Seems like this is good?

• YES!
• THANK YOU AC!
• Shifting Gears

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What is CQI?

• CQI is an approach to quality management that
  builds upon traditional quality assurance methods
  by emphasizing the organization and systems
• Focuses on "process" rather than the individual
• Recognizes both internal and external "customers"
• Promotes the need for objective data to analyze
  and improve processes
• Incorporates a team approach to achieve goals
• Focused on rapid change (thus not RCT, no
  controls etc)

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Steps of CQI

• Core Steps in Continuous Improvement
• Form a team that has knowledge of the system
  needing improvement
• Define a clear aim
• Understand the needs of the people who are served
  by the system
• Identify and define measures of success
• Brainstorm potential change strategies for
  producing improvement
• Plan, collect, and use data for facilitating
  effective decision making
• Apply the scientific method to test and refine
  changes

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CQI Model for ImprovementFundamental Questions
for Improvement

• Aim
• Measures
• Changes/Evidence-based strategies

What are we trying to accomplish?
How will we know that changes are an improvement?
What changes can we make that will result in
an improvement?
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What is PDSA?

• PDSA Cycle was originally conceived by Walter
  Shewhart in 1930's, and later adopted by W.
  Edwards Deming
• Provides a framework for the improvement of a
  process or system
• Can be used to guide the entire project or to
  develop specific projects once target improvement
  areas have been identified

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
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PDSA Plan-Do-Study-Act Cycles for Testing Change

• Plan
• What are your aims and goals for this cycle?
• Predictions/Hypothesis
• Develop plan to test the change
• What will your measures be? Develop plan for data
  collection
• Do
• Perform your test/change
• Collect data
• Study
• Analyze your data (quantitative and qualitative)
• Did the results fit your predictions?
• Did you encounter problems?
• What did you learn?
• Act
• Did you achieve your aims and goals?
• Should you expand size/scope of test. Are you
  ready to spread/implement the change?
• If not, what changes are needed for next PDSA
  cycle?

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PDSA CyclesTests of Change to Drive Improvement
Changes that result in improvement
Learning
Learning
Cycle 3 Aims Measures Changes
Cycle 2 Aims Measures Changes
Cycle 1 Aims Measures Changes
Ideas
DeWalt
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My project Why study AC?

• Our AC has not been previously studied as part of
  CQI
• Coumadin has a very narrow therapeutic range thus
  patient adherence/safety is crucial
• Combined experience from working in AC and
  Hospital lead to an idea for improvement
• In an effort to promote health care literacy,
  this clinic population is a wonderful focus

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Literacy and Coumadin

• Healthy People 2010 defines health literacy as
• the degree to which individuals have the
  capacity to obtain, process, and understand basic
  health information and services needed to make
  appropriate health decisions

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Literacy and Coumadin - Risks

• Health literacy is of particular importance when
• substantial patient-provider discussion of risks
  and benefits are needed
• conditions requiring complex management
• Studies have indicated that poorer patient
  knowledge about warfarin and lack of education
  from providers are associated with
• worse anticoagulation control
• increased frequency of hemorrhagic events

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Literacy and Coumadin

• Few studies have examined the prevalence of
  limited health literacy among anticoagulated
  patients
• Is health literacy associated with
  anticoagulation knowledge and control of warfarin
  therapy?
• Do barriers to communication and comprehension
  contribute to
• Under treatment?
• Withholding of therapy among eligible patients?
• (phenomenon that disproportionately affects
  elderly and racial/ethnic minorities)

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CQI Health Literacy in AC

• Project Aims
• Improve patient compliance
• Understand patient perception of medication/ease
  of use
• particularity in early stages of initiating
  therapy
• ID a Target Population Those who would most
  benefit from the intervention
• Project Change/Intervention
• Implement a color printed visual medication
  calendar for warfarin specific for each patient

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Current Method

• Verbal communication of medication regimens
• Additionally a hand written weekly chart is often
  used
• Problems with the current method
• Hand written charts are not always used
• Some patients cannot read (due to literacy or
  vision problems) or have difficulty calculating
  dose or interpreting the current chart provided
• Patients may have one or more strength of
  warfarin at home (risk they would take the wrong
  tablet)

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Plan

• Develop a survey to understand patient
  perceptions about their warfarin regimen
• Have patients evaluate a color, visual medication
  calendar specific to them and get their feedback
• Reevaluate chart and implement for a second PDSA
  cycle

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Chart Development

• Shaun created a coumadin calendar based on the
  old coumadin calendar, but incorporated actual
  pictures of coumadin or warfarin
• Pictures of all available strengths were made
  available
• Designed an entry form within the current
  anticoagulation database used by the AC clinic to
  make this user friendly and patient specific

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Coumadin Calendar Data Entry
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Next Step

• Get the chart in patients hands
• Have patients evaluate the new chart in the form
  of a survey and give feedback
• Will this be beneficial to our clinic population?
• Can we refine our target population who will
  receive the chart?
• Arbitrary goal 20 patients actual 26

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Specific questions to address

• Will visual medication chart improve patients
  perception of their compliance?
• Will visual medication simplify patients
  perception of their medication regimen?
• Will patients find this method easier than the
  current method?

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Survey

• Nurse please ask the following questions.
• How confident are you that you take the correct
  dosage of warfarin/Coumadin at home?
• VERY CONFIDENT SOMEWHAT CONFIDENT
  NOT CONFIDENT
• How many times a week do you think you make a
  mistake taking your warfarin/Coumadin?
• 0 1 - 2 3
• Do you have a hard time figuring out your dose
  (number of pills) at home?
• YES NO
• Do you have a hard time remembering dose changes
  once you get home?
• YES NO
• Do you always get a new medication chart with
  Coumadin/warfarin dose changes?
• YES NO
• Is it easy to understand the current
  Coumadin/warfarin medication chart?
• YES NO
• Anticoag provider please print out the new
  visual medication chart and ask the following
  questions.
• Do you think this new chart will make it easier
  for you to figure out the dose (number of pills)
  at home?
• YES NO
• Do you think this new chart would help you
  remember your dose, especially if your dose was
  recently changed?
• YES NO

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Survey Results

• A total of 26 patients were presented with the
  chart and completed survey questions
• 88 felt some part of the chart was beneficial
• 6 of the patients reported difficulty with
  remembering their dose or felt they
  inappropriately took meds
• 100 felt all aspects of the chart were
  beneficial
• Potential target population
• (remember not an RCT)

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Target Populations to Track

• New Starts
• Patients that have not yet started
  anticoagulation
• Potential for Improvement
• Patients who are not at steady state requiring
  dose adjustments
• Patients who have demonstrated adherence issues
  in the past
• Patients with an INR that is out of range

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What Next?

• Improved chart based on AC provider suggestions
• Added ways to place hold on certain days
• Added a second week for specific changes

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Coumadin Calendar Data Entry
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What next?

• Currently do not have a measure to show
  intervention improves patient outcomes
• Next PDSA cycle
• Focus on our target population to determine if
  people who received the chart have better outcomes

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The Future

• New Starts
• Compare to a similar new start group before
  development of the visual chart
• Potential for Improvement
• See how their INR tracks from 12 weeks prior to
  12 weeks post intervention with the medication
  chart

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What to measure?

• Thus, a discussion of outcome measures is
  warranted
• 1. Does this improve TTR, the tracking period of
  this would be 12 weeks?
• 2. Does this reduce time to first therapeutic
  INR?
• 3. Does this reduce the number of clinic visits?
• 4. Is there a reduction in either thromboembolic
  events from subtherapeutic INRs or a reduction in
  bleeding from supratherapeutic INRs?
• again not RCT

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Suggestions?
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THANKS TO!

• Annie Whitney - answering innumerable Qs and
  letting me do something different
• Bart Scott and Carrie Palmer - putting up with
  the printer
• Shaun McDonald - creating chart, entry system and
  tracking system very efficiently
• Eva Wamagata and Stephanie Degraffenreid -
  administering survey
• Robb Malone - helping with future plans
• Dan Jonas - for his input with the initial
  project
• Betsy Bryant - for helping while on leave!
• Paul Chelminski - supporting residents with
  alternative/unconventional ideas

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References

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References

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