Top Performing VA Anticoagulation Clinics Share Characteristics
Warfarin - an oral anticoagulant - requires routine blood tests to ensure that patients are sufficiently anticoagulated to prevent blood clots, but not so thoroughly anticoagulated as to place them at excessive risk of bleeding. VA requires that all Veterans receiving warfarin be managed in a dedicated anticoagulation clinic (ACC), which can improve anticoagulation control and prevent adverse events. Nevertheless, even among patients receiving treatment in an ACC, there is substantial variation in anticoagulation control. This study compared the organization and management of three top-performing VA ACCs (high-outliers) with three bottom-performing VA ACCs (low-outliers), based on a recent study. These sites represented six states and all U.S. geographic regions. Investigators conducted interviews with ACC staff regarding work flow, staffing, organization, and quality assurance efforts. They also observed operations (four hours of clinical care) and examined documents (e.g., clinic protocol, medical record templates) at each site. While ACC sites were selected based on their performance from 10/06 through 9/08, site visits occurred between 5/10 and 3/11.
- The top performing VA anticoagluation clinics shared six characteristics:
- Adequate pharmacist staffing and effective use of non-pharmacist personnel;
- Innovation to standardize clinical practice around evidence-based guidelines;
- Presence of a quality champion for the ACC;
- Higher staff qualifications (e.g., all pharmacists had completed pharmacy residencies);
- Climate of ongoing group learning; and
- Internal efforts to measure performance.
- No low-outlier ACC had more than two of these characteristics. Therefore, the authors suggest that efforts to improve performance should focus on the six common domains.
- At least five domains were not associated with ACC performance, including use of the electronic medical record, and configuration of the clinic (e.g., face-to-face patient contact vs. telephone care).
- Investigators were unable to gain access to some of the worst-performing ACCs in the VA system, primarly due to lack of an IRB of record.
- A considerable amount of time elapsed between the initial measurement period and site visits.
- Neither the site visitor nor analyses were blinded to outlier status.
This study was funded by VA/HSR&D's Stroke Quality Enhancement Research Initiative (Stroke-QUERI; RRP 10-054). Dr. Rose also was supported by an HSR&D Career Development Award. Drs. Rose, Hylek, and Bokhour and Ms. Petrakis are part of HSR&D's Center for Health Quality, Outcomes and Economic Research in Bedford, MA.
Rose A, Petrakis B, Callahan P, Mambourg S, Patel D, Hylek E, and Bokhour B. Organizational Characteristics of High- and Low-Performing Anticoagulation Clinics in the Veterans Health Administration. Health Services Research February 2, 2012;e-pub ahead of print.