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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3082 — Projected Benefits of Quality Improvement in Oral Anticoagulation for Patients with Atrial Fibrillation

Rose AJ (Bedford VAMC), McCarron TJ (Bedford VAMC), Berlowitz DR (Bedford VAMC), Hylek EM (Boston University), Ozonoff A (Children's Hospital of Boston), Ash AS (University of Massachusetts), Goldhaber-Fiebert JD (Stanford University)

Better anticoagulation control, as measured by percent time in therapeutic range (TTR), can prevent adverse events. We have previously shown that VHA patients with atrial fibrillation (AF) achieve a mean TTR of 62.4%, which leaves much room for improvement. Our objective was to simulate the number of adverse events that might be averted within VHA by improving TTR for these patients, and to explore the cost and health implications of these averted events.

Our study is based upon 67,077 VHA patients with AF anticoagulated between 10/1/06 - 9/30/08. Basing our models upon previous literature, we used the comorbidities of our VHA patients (i.e. CHADS2 scores) and their anticoagulation control (TTR) to simulate the incidence of ischemic stroke, major hemorrhage, and all-cause mortality. We then varied the simulation by assuming that TTR had improved by 5% (modestly improved) or 10% (substantially improved). Under each scenario, we computed changes in quality adjusted life years (QALYs) and costs (using Medicare cost estimates) compared to the status quo.

In the status quo scenario, 26.0% of patients experienced any adverse event. Improving TTR by 5% reduced this to 24.2%, preventing 1,218 events. Improving TTR by 10% reduced this to 22.6%, preventing 2,259 events. Many events prevented were deaths; for example, a 5% improvement prevented 551 deaths, 424 strokes, and 243 major hemorrhages. A 5% improvement in TTR gained 1,543 QALYs and saved $17,874,149 over the two-year study, while a 10% improvement gained 3,018 QALYs and saved $32,601,628. Thus, VHA could invest up to $133 per patient-year on a QI initiative to improve anticoagulation control, and even if TTR improved by only 5%, the program would still be cost-saving.

Even small improvements in anticoagulation control could prevent thousands of adverse events in VHA each year. VHA could spend up to $17 million to improve TTR by a minimal amount (5%) and the intervention would still be cost-saving.

By improving the quality of oral anticoagulation, VHA has an opportunity to improve outcomes for our veterans while saving money. Our study suggests that improving oral anticoagulation should be a top priority for VHA.

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