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Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin.

ABSTRACT: Introduction:Studies have shown that achieving a time in therapeutic range (TTR) for warfarin of greater than 60% is associated with a lower risk of bleeding. However, many patients on hemodialysis (HD) do not achieve this target. Methods:We audited TTR achievement at the in-center HD unit of our hospital in 2017 and found that only 40% of patients had achieved a TTR >60%. We aimed to improve the percentage of HD patients achieving target TTR within 2 years. We reported each patient's individualized trend in quarterly TTR to their primary warfarin prescriber as an audit-feedback report. These reports were generated, disseminated, and subsequently improved following a series of plan-do-study-act cycles. We then used statistical process control to assess for changes in the percentage of HD patients achieving target TTR over time. Results:In the primary analysis, 28 patients were included in the baseline period, and 46 were included in the intervention period. At baseline, the percentage of patients achieving a TTR >60% varied between 33% and 45% (mean ± SD, 40% ± 5%); post-intervention, this metric improved and varied between 52% and 71% (mean ± SD, 61% ± 8%). In time-series analysis, there was evidence of statistically significant variation between the 2 periods and evidence of sustained improvement. Conclusions:A quality improvement program consisting of an audit-feedback report that raises awareness of the quality gap in TTR achievement can result in substantial improvement in the safe and efficacious administration of warfarin to patients receiving maintenance hemodialysis.

SUBMITTER: Blum D

PROVIDER: S-EPMC7000800 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin.

Blum Daniel D Beaubien-Souligny William W Battistella Marisa M Tseng Eric E Harel Ziv Z Nijjar Jaspreet J Nazvitch Elena E Silver Samuel A SA Wald Ron R

Kidney international reports 20191106 2

<h4>Introduction</h4>Studies have shown that achieving a time in therapeutic range (TTR) for warfarin of greater than 60% is associated with a lower risk of bleeding. However, many patients on hemodialysis (HD) do not achieve this target.<h4>Methods</h4>We audited TTR achievement at the in-center HD unit of our hospital in 2017 and found that only 40% of patients had achieved a TTR >60%. We aimed to improve the percentage of HD patients achieving target TTR within 2 years. We reported each patie ...[more]

PMID: 32043029

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Project description:Thromboembolic events are associated with high mortality and morbidity indexes. In this context, warfarin is the most widely prescribed oral anticoagulant agent for preventing and treating these events. This medication has a narrow therapeutic range and, consequently, patients usually have difficulty in achieving and maintaining stable target therapeutics. Some studies on the literature about oral anticoagulant management showed that pharmacists could improve the efficiency of anticoagulant therapy. However, the majority of these studies included general patients retrospectively. The aim of this study was to prospectively evaluate a pharmacist's warfarin management in patients with poor quality of anticoagulation therapy (Time in the Therapeutic Range- TTR < 50%). We included 268 patients with atrial fibrillation (AF) and without stable dose of warfarin (TTR < 50%, based on the last three values of International Normalized Ratio-INR). We followed them up for 12 weeks, INR values were evaluated and, when necessary, the dose adjustments were performed. During the first four visits, patient's INR was measured every 7 days. Then, if INR was within the target therapeutic range (INR: 2-3), the patient was asked to return in 30 days. However, if INR was out the therapeutic target, the patient was asked to return in 7 days. Adherence evaluation was measured through questionnaires and by counting the pills taken. Comparison between basal TTR (which was calculated based on the three last INR values before prospective phase) and TTR of 4 weeks (calculated by considering the INR tests from visits 0 to 4, in the prospective phase of the study) and basal TTR and TTR of 12 weeks (calculated based on the INR tests from visits 0 to 12, in the prospective phase of the study) revealed significant statistical differences (0.144 ± 0.010 vs. 0.382 ± 0.016; and 0.144 ± 0.010 vs. 0.543 ± 0.014, p < 0.001, respectively). We also observed that the mean TTR of 1 year before (retrospective phase) was lower than TTR value after 12 weeks of pharmacist-driven treatment (prospective phase) (0.320 ± 0.015; 0.540 ± 0.015, p < 0.001). In conclusion, pharmaceutical care was able to improve TTR values in patients with AF and poor quality of anticoagulation with warfarin.

Project description:This project aims to assess the impact of the introduction of a hepatobiliary and pancreatic (HPB) Quality Improvement Program (QIP) on postoperative complications following liver, biliary and pancreatic surgery. A prospective analysis of postoperative complications over a six month period was performed. Complications were analysed and graded according to internationally agreed definitions. Justification was sought and errors identified. Weekly meetings were performed to review each complication enabling an action plan to be created to prevent future recurrence. Rates were compared with previously audited and published results, using the chi-square test. A total of 326 procedures were performed over the six months including 30 pancreatectomies, 45 liver resections and 251 other procedures. 37 patients developed complications (11.3%) with 47 complications in total including two deaths. Using the ISGPS grading, eight complications were identified; two grade A, four grade B and two grade C. There were three grade A ISGLS complications and one grade B. 30 complications were justified as unavoidable, 16 as avoidable and one as indeterminate. Action plans included continued monitoring (n=41), formulation of new policy (n=3), individual counselling (n=4), educational offering (n=4). When compared with 2010 complication rates, 114 complications occurred in 233 liver operations during the baseline period, compared with 17 complications in 45 liver operations during the QIP period, OR=0.63 (95% CI: 0.33 to 1.22), p=0.17 and 86 complications occurred in 99 pancreatic resections during the baseline period, compared with 20 complications in 30 pancreatic resections during the QIP period OR=0.30 (95% CI: 0.12 to 0.79), p=0.01 The HPB QIP is a rigorous approach to grade every complication and death. A statistically significant reduction in pancreas related complications has already been obtained. Further work is required to determine the persistence and magnitude of this quality improvement.

Project description:Rationale & objectivePatients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis.Study designProspective controlled quality improvement study with a contemporaneous control.Setting & participantsPatients prescribed ≥5 medications in 2 outpatient dialysis units in Montréal, Canada.ExposuresPatient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone.Analytical approachThe proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated.OutcomesThe primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline.ResultsIn total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8 ± 15.9 (SD), and 36.9% were women. The proportion of patients with ≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P < 0.0001; number needed to treat = 3).LimitationsThis was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events.ConclusionsDeprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.

Project description:BackgroundAlthough previous research has demonstrated that referral to pre-dialysis clinics is associated with favourable objective outcomes, the benefit of a pre-dialysis clinic from the perspective of patient-perceived subjective outcomes, such as quality of life (QOL), is less well defined.MethodsA retrospective incident cohort study was conducted to determine if pre-dialysis clinic attendance was a predictor of better QOL scores measured within the first six months of hemodialysis (HD) initiation. Inclusion criteria were HD initiation from January 1 1998 to January 1 2000, diagnosis of chronic renal failure, and completion of the QOL questionnaire within six months of HD initiation. Patients receiving HD for less than four weeks were excluded. An incident cohort of 120 dialysis patients was identified, including 74 patients who attended at least one pre-dialysis clinic and 46 patients who did not. QOL was measured using the SF 36-Item Health Survey. Independent variables included age, sex, diabetes, pre-dialysis clinic attendance and length of attendance, history of ischemic heart disease, stroke, peripheral vascular disease, heart failure, malignancy, and chronic lung disease, residual creatinine clearance at dialysis initiation, and kt/v, albumin and hemoglobin at the time of QOL assessment. Bivariate and multivariate linear regression analyses were used to identify predictors of QOL scores.ResultsMultivariate analysis suggested that pre-dialysis clinic attendance was an independent predictor of higher QOL scores in four of eight health domains (physical function, p < 0.01; emotional role limitation, p = 0.01; social function, p = 0.01; and general health, p = 0.03), even after statistical adjustment for age, sex, residual renal function, kt/v, albumin, and co-morbid disease. Pre-dialysis clinic attendance was also an independent predictor of the physical component summary score (p = 0.03).ConclusionsWe conclude that pre-dialysis clinic attendance favourably influences patient-perceived quality of life within six months of dialysis initiation.

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Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin.

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Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin.

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