BACKGROUND/RATIONALE:
Improved control can improve both the safety and effectiveness of oral anticoagulation. However, as of the inception of this award, the VA did not have an organized program of quality measurement in oral anticoagulation. There was a need to demonstrate how such a program might be constructed, what quality measures it might use, and how the VA could work to improve anticoagulation control.

OBJECTIVE(S):
1. To derive and validate a risk adjustment model for percent time in therapeutic range (TTR), a measure of anticoagulation control over time.
2. To profile VA sites of care by oral anticoagulation control, as measured by risk-adjusted TTR (RA-TTR).
3. To examine site-level structures and processes of care that relate to RA-TTR.
4. Using qualitative methods, characterize the organization and management of three high-outlier and three low-outlier sites, as characterized by RA-TTR.

METHODS:
Objectives 1 and 2: We included almost 125,000 VA patients who received oral anticoagulation from VA in the two-year period encompassing FY07-FY08. We calculated TTR for each patient and the mean TTR for each site of care. We used patient-level data, including sociodemographics and comorbid conditions, to derive and validate a risk adjustment model for TTR. We then profiled 100 VA sites of care on risk-adjusted TTR (RA-TTR).

Objective 3: We used a survey administered by VA Pharmacy Benefits Management (PBM) to characterize structure of care at VA Anticoagulation Clinics (ACCs). Each site's responses to the survey were compared to that site's performance, as measured by RA-TTR. In addition, we examined multiple site-level processes of care (follow-up intervals, gaps in monitoring, and mean INR values) and their relationship with site-level performance on RA-TTR.

Objective 4: We visited three of the best-performing sites and three of the worst-performing sites on RA-TTR. We collected data through three methods: semi-structured interviews with ACC staff, direct observation of ACC operations, and collection of ACC-related documents such as the clinic protocol. We analyzed these data using qualitative methods to paint a portrait of each of these 6 sites.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Our work on RA-TTR was the subject of a CO Executive Brief and has generated enthusiasm for VA-wide measurement of anticoagulation control. Our site visits to high and low outlier sites on TTR performance was also the subject of a CO Executive Brief and has generated considerable interest. Our implementation project, "Improving Anticoagulation Control in VISN 1", began in October 2012. The goal of this project is be to improve TTR in VISN 1 from its 62% up to 75% or more, which would represent world-class performance. After demonstrating that this can be achieved in VISN 1, we will work to disseminate this project throughout the entire VA system. TTR in VISN 1 has already improved from 62% to a current level of 64.6%, despite the fact that our intervention has had less than a year to work and the fact that TTR is inherently time-lagged as a performance measure. This promising early result suggests that we will be successful in achieving our goals.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Jasuja GK, Travison TG, Davda M, Murabito JM, Basaria S, Zhang A, Kushnir MM, Rockwood AL, Meikle W, Pencina MJ, Coviello A, Rose AJ, D'Agostino R, Vasan RS, Bhasin S. Age trends in estradiol and estrone levels measured using liquid chromatography tandem mass spectrometry in community-dwelling men of the Framingham Heart Study. The journals of gerontology. Series A, Biological sciences and medical sciences. 2013 Jun 1; 68(6):733-40. [view]
2. Rose AJ, Ozonoff A, Henault LE, Hylek EM. Anticoagulation for valvular heart disease in community-based practice. Thrombosis and Haemostasis. 2010 Feb 1; 103(2):329-37. [view]
3. Rothendler JA, Rose AJ, Reisman JI, Berlowitz DR, Kazis LE. Choices in the use of ICD-9 codes to identify stroke risk factors can affect the apparent population-level risk factor prevalence and distribution of CHADS2 scores. American journal of cardiovascular disease. 2012 Jul 25; 2(3):184-91. [view]
4. Jasuja GK, Travison TG, Davda M, Rose AJ, Zhang A, Kushnir MM, Rockwood AL, Meikle W, Coviello AD, D'Agostino R, Vasan RS, Bhasin S. Circulating estrone levels are associated prospectively with diabetes risk in men of the Framingham Heart Study. Diabetes Care. 2013 Sep 1; 36(9):2591-6. [view]
5. Rose AJ, Berlowitz DR, Manze M, Orner MB, Kressin NR. Comparing methods of measuring treatment intensification in hypertension care. Circulation. Cardiovascular quality and outcomes. 2009 Jul 1; 2(4):385-91. [view]
6. Rose AJ, Hermos JA, Frayne SM, Pogach LM, Berlowitz DR, Miller DR. Does opioid therapy affect quality of care for diabetes mellitus? The American journal of managed care. 2009 Apr 1; 15(4):217-24. [view]
7. Rose AJ, Glickman ME, D'Amore MM, Orner MB, Berlowitz D, Kressin NR. Effects of daily adherence to antihypertensive medication on blood pressure control. Journal of clinical hypertension (Greenwich, Conn.). 2011 Jun 1; 13(6):416-21. [view]
8. Rose AJ, Ozonoff A, Grant RW, Henault LE, Hylek EM. Epidemiology of subtherapeutic anticoagulation in the United States. Circulation. Cardiovascular quality and outcomes. 2009 Nov 1; 2(6):591-7. [view]
9. Rose AJ, Miller DR, Ozonoff A, Berlowitz DR, Ash AS, Zhao S, Reisman JI, Hylek EM. Gaps in monitoring during oral anticoagulation: insights into care transitions, monitoring barriers, and medication nonadherence. Chest. 2013 Mar 1; 143(3):751-7. [view]
10. Rose AJ, Hylek EM. High blood pressure while taking antithrombotic medication is associated with an increased risk of developing intracranial haemorrhage. Evidence-based medicine. 2010 Dec 1; 15(6):189-90. [view]
11. Jasuja GK, Reisman JI, Miller DR, Berlowitz DR, Hylek EM, Ash AS, Ozonoff A, Zhao S, Rose AJ. Identifying major hemorrhage with automated data: results of the Veterans Affairs study to improve anticoagulation (VARIA). Thrombosis research. 2013 Jan 1; 131(1):31-6. [view]
12. Efird LM, Miller DR, Ash AS, Berlowitz DR, Ozonoff A, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Identifying the risks of anticoagulation in patients with substance abuse. Journal of general internal medicine. 2013 Oct 1; 28(10):1333-9. [view]
13. Rose AJ, Berlowitz DR, Miller DR, Hylek EM, Ozonoff A, Zhao S, Reisman JI, Ash AS. INR targets and site-level anticoagulation control: results from the Veterans AffaiRs Study to Improve Anticoagulation (VARIA). Journal of Thrombosis and Haemostasis : Jth. 2012 Apr 1; 10(4):590-5. [view]
14. Rose AJ, Berlowitz DR, Manze M, Orner MB, Kressin NR. Intensifying therapy for hypertension despite suboptimal adherence. Hypertension. 2009 Sep 1; 54(3):524-9. [view]
15. Rose AJ, Berlowitz DR, Frayne SM, Hylek EM. Measuring quality of oral anticoagulation care: extending quality measurement to a new field. Joint Commission Journal on Quality and Patient Safety. 2009 Mar 1; 35(3):146-55. [view]
16. Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM, Bokhour BG. Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration. Health services research. 2012 Aug 1; 47(4):1541-60. [view]
17. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA). Journal of Thrombosis and Haemostasis : Jth. 2010 Oct 1; 8(10):2182-91. [view]
18. Rose AJ, Hylek EM, Berlowitz DR, Ash AS, Reisman JI, Ozonoff A. Prompt repeat testing after out-of-range INR values: a quality indicator for anticoagulation care. Circulation. Cardiovascular quality and outcomes. 2011 May 1; 4(3):276-82. [view]
19. Rose AJ, Ozonoff A, Berlowitz DR, Ash AS, Reisman JI, Hylek EM. Reexamining the recommended follow-up interval after obtaining an in-range international normalized ratio value: results from the Veterans Affairs study to improve anticoagulation. Chest. 2011 Aug 1; 140(2):359-65. [view]
20. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Callahan PP, Gordon MM, Berlowitz DR. Relevance of current guidelines for organizing an anticoagulation clinic. The American journal of managed care. 2011 Apr 1; 17(4):284-9. [view]
21. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Risk-adjusted percent time in therapeutic range as a quality indicator for outpatient oral anticoagulation: results of the Veterans Affairs Study to Improve Anticoagulation (VARIA). Circulation. Cardiovascular quality and outcomes. 2011 Jan 1; 4(1):22-9. [view]
22. Rose AJ, Berlowitz DR, Ash AS, Ozonoff A, Hylek EM, Goldhaber-Fiebert JD. The business case for quality improvement: oral anticoagulation for atrial fibrillation. Circulation. Cardiovascular quality and outcomes. 2011 Jul 1; 4(4):416-24. [view]
23. Berz JP, Johnston K, Backus B, Doros G, Rose AJ, Pierre S, Battaglia TA. The influence of black race on treatment and mortality for early-stage breast cancer. Medical care. 2009 Sep 1; 47(9):986-92. [view]
24. Marrast L, Evans M, Ozonoff A, Henault LE, Rose AJ. Using highly variable warfarin dosing to identify patients at risk for adverse events. Thrombosis journal. 2011 Oct 10; 9:14. [view]
25. Rose AJ, Ozonoff A, Berlowitz DR, Henault LE, Hylek EM. Warfarin dose management affects INR control. Journal of Thrombosis and Haemostasis : Jth. 2009 Jan 1; 7(1):94-101. [view]
26. Rose AJ, Ozonoff A, Henault LE, Hylek EM. Warfarin for atrial fibrillation in community-based practice. Journal of Thrombosis and Haemostasis : Jth. 2008 Oct 1; 6(10):1647-54. [view]

Journal Other

1. Wasserman MS, Rose AJ. An unusual presenting complaint for herpes zoster. The American journal of medicine. 2013 Jun 1; 126(6):e3-4. [view]
2. Rose AJ. Improving the management of warfarin may be easier than we think. Circulation. 2012 Nov 6; 126(19):2277-9. [view]
3. Rose AJ. Patient education: the missing link in improving quality of oral anticoagulation. [Editorial]. Cardiology. 2010 Sep 16; 116(1):59-60. [view]

Magazine/Popular Press Articles

1. Rose AJ, Hylek EM, Berlowitz DR. Measuring and Improving Quality of Oral Anticoagulation for Veterans. Federal Practitioner. 2013 Mar 1; 3(3):34-6. [view]

Conference Presentations

1. Razouki Z, Rose AJ. A new perspective in anticoagulation: Understanding time spent above and below the target range among patients receiving warfarin at the VA health care system. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO. [view]
2. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Adjusted Percent Time in Range as a Quality Indicator for Oral Anticoagulation Care. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
3. Ambrus DB, Reisman JI, Rose AJ. Cancer type predicts outcomes of warfarin therapy. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO. [view]
4. Rose AJ, Berlowitz DR, Manze M, Orner MB, Kressin NR. Comparing Methods of Measuring Treatment Intensification in Hypertension Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL. [view]
5. Benedict A, Rose AJ, Park A, Fu A, Schlosser J. Evaluation of Multiple Anticoagulation Delivery Methods using Observations and Time Studies. Paper presented at: Industrial and Systems Engineering Research Conference; 2013 May 18; San Juan, PR. [view]
6. Efird L, Rose AJ. Identifying the risks of anticoagulation in patients with substance abuse. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO. [view]
7. Efird L, Rose AJ. Identifying the risks of oral anticoagulation in patients with liver disease. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO. [view]
8. Kanaan AO, Donovan JL, Ozkaynak M, Johnson S, Tulu B, Rose AJ. Integrating clinical pharmacists and industrial engineers’ perspectives to develop a codebook to characterize structure at anticoagulation clinics. Poster session presented at: American College of Clinical Pharmacy Annual Meeting; 2012 Oct 21; Hollywood, FL. [view]
9. Ozkaynak M, Tulu B, Kanaan A, Donovan J, Rose AJ, Johnson S. Opportunities for Better Anticoagulation Management. Poster session presented at: American Medical Informatics Association Annual Symposium; 2012 Nov 3; Chicago, IL. [view]
10. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Patient-Level Predictors of Outpatient Anticoagulation Control. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
11. Kim EJ, Rose AJ. Predicting Outcomes among Patients with Heart Failure Receiving Anticoagulation with Warfarin. Paper presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2013 May 15; Baltimore, MD. [view]
12. Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Prolonged Follow-Up Intervals Are Associated with Poorer Control in Outpatient Oral Anticoagulation. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
13. Rose AJ. Quality of Oral Anticoagulation Care in VHA. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2011 Feb 15; National Harbor, MD. [view]
14. Rose AJ, Berlowitz DR, Manze M, Orner MB, Kressin NR. Treatment Intensification Improves Blood Pressure Control Both in Adherent and Non-Adherent Patients. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami, FL. [view]
15. Ozkaynak M, Rose AJ. Understanding the Work System at Anticoagulation Clinics. Paper presented at: Industrial and Systems Engineering Research Conference; 2013 Apr 15; Orlando, FL. [view]
16. Rose AJ, Ozonoff A, Henault LE, Hylek EM. Warfarin for Atrial Fibrillation in Community-Based Practice. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA. [view]

DRA: Health Systems
DRE: Prevention, Technology Development and Assessment, Treatment - Observational
Keywords: none
MeSH Terms: none