BACKGROUND/RATIONALE:
Among patients receiving oral anticoagulation, better control reduces the risk of serious adverse events including stroke, major hemorrhage, and death. We have documented a wide variation in performance among VHA anticoagulation clinics (ACCs) regarding anticoagulation control. However, we have a limited understanding of the underlying reasons why performance varies so widely among VHA anticoagulation clinics.

OBJECTIVE(S):
Our objective was to understand the organization, management, and day-to-day operations of six VHA ACCs, three of which have excellent performance ("high outlier") and three of which have poor performance ("low outlier"). We aimed to understand the organization and management correlates of performance.

METHODS:
We visited the six ACCs and interviewed all ACC staff. We also directly observed clinic operations and collected clinic-related documents. We used qualitative methods to analyze the interview transcripts, field notes, and documents, and used them to construct a summary of how each clinic is run. We used constant comparison to understand the differences among clinics, particularly as they relate to performance.

FINDINGS/RESULTS:
The configuration of the ACC (telephone clinic, face-to-face clinic, venous blood draws vs. point-of-care device) was not related to quality of care; both high and low ACCs had a variety of configurations according to local needs. High outliers were generally characterized by efforts to standardize clinical practice around current evidence and guidelines, adequate staffing levels, dedicated time for ACC duties, higher qualifications of staff, rigorous initial and ongoing training for staff, the presence of a quality champion, and internal efforts to measure and improve performance. Low outliers were generally characterized by the absence of at least some of these features.

Some details follow about the general observations noted above. The organization of practice around evidence and guidelines was most often accomplished through the use of well-designed templates for progress notes and consults. Staff at low outlier clinics felt rushed, and were objectively observed to be rushed, while staff at high outlier clinics had more time to consider each patient carefully. This was also partly due to the fact that high-outlier clinics protected ACC providers' time for ACC duties, while low-outlier sites allowed them to have other responsibilities on ACC days. High outlier clinics had at least one strong quality champion, who could be either the lead pharmacist for the ACC or a member of the pharmacy administration. High outlier clinics measured their own performance, often at great effort and expense, even when they lacked systems to accomplish this easily.

IMPACT:
The results of this study will serve as the basis for an effort to improve anticoagulation control in the VHA, which would prevent thousands of adverse events each year among our veterans if it is successful. In addition, our understanding of the anatomy of an excellent pharmacy-run clinic will have applications beyond ACCs to other pharmacy-run clinics in the VHA system, including clinics to manage hypertension, hyperlipidemia, narcotics for chronic pain, diabetes, and other chronic conditions.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Ozkaynak M, Johnson SA, Tulu B, Donovan JL, Kanaan AO, Rose A. Exploring the effect of complex patients on care delivery tasks. International journal of health care quality assurance. 2015 Jan 1; 28(5):494-509. [view]
2. 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]

Journal Other

1. 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. [Abstract]. Pharmacotherapy. 2012 Oct 2; 32(10):e225. [view]

Conference Presentations

1. 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]
2. 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]
3. 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]
4. 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]
5. 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]

DRA: Cardiovascular Disease
DRE: Treatment - Observational, Treatment - Comparative Effectiveness
Keywords: Care Management, Pharmaceuticals, Stroke
MeSH Terms: none