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Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs

The benefit of long-term anticoagulation with warfarin to prevent ischemic stroke in patients with atrial fibrillation (AF) is well-established; however, the anticoagulation that is actually provided leaves much room for improvement. Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Using data from a previous VA study, investigators identified 67,077 Veterans with AF who had received anticoagulation from VA over a two-year period (10/06 – 9/08). Investigators then simulated the number of adverse events (i.e., ischemic stroke, major hemorrhage, and death) that would be prevented in this population through improved TTR, as well as the resulting cost savings and utility gains (quality adjusted life years, QALYs). Costs for ongoing warfarin therapy and for adverse events that might be prevented or caused by warfarin therapy were included. Costs were expressed in 2008 dollars.


  • Even after considering the cost of implementing the program, a quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs.
  • In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the quality improvement program) and a gain of 863 QALYs over the two-year study period. Improving TTR by 10% prevented 2,087 events, gained 1,606 QALYs, and saved $29.7 million (again, minus the cost of the quality improvement program).

The usual cost of a quality improvement program in VA is less than $1 million. Thus, there is likely a compelling business case for an anticoagulation QI program. For example, if the program achieved a modest 5% improvement in TTR, it could cost as much $59 million and still achieve cost-effectiveness.


  • Patient comorbidities were assessed using ICD-9 scores, which can be inaccurate.
  • Instead of using VA cost data, investigators used Medicare cost estimates to enhance generalizability to most settings.
  • Utility estimates were derived from a general population rather than a VA population, and this study did not include the inherent disutilities of comorbid conditions, old age, and ill health. This omission somewhat overstates benefits, although the extent is limited by the two-year time period.

This study was funded by HSR&D, and Dr. Rose was supported by an HSR&D Career Development Award. Drs. Rose and Berlowitz are part of HSR&D’s Center for Health Quality, Outcomes, and Economic Research in Bedford, MA.

PubMed Logo Rose A, Berlowitz D, Ash A, et al. The Business Case for Quality Improvement: Oral Anticoagulation for Atrial Fibrillation. Circulation: Cardiovascular Quality and Outcomes 2011 Jul 1;4(4):416-24.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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