Improving Anticoagulation Control in VISN 1

Background: Over 100,000 VA patients receive oral anticoagulation (AC) each year to prevent
blood clots, including strokes. AC is safer and more effective when it is managed skillfully
and therefore well-controlled. AC control can be measured using percent time in therapeutic
range (TTR), the proportion of time when patients are sufficiently anticoagulated to prevent
clots but not excessively anticoagulated (which increases the risk of bleeding). The
investigators have shown that the anticoagulation clinics (ACCs) of the VA vary widely on
TTR, from 40% (very poor control) to 70% (excellent control). Improving TTR in the VA would
prevent thousands of adverse events, including strokes, major hemorrhages, and deaths. The
investigators have further investigated the structures and processes of care that contribute
to these wide disparities in TTR performance.

Objectives: In this proposed study, the investigators will apply proven methods to change
provider behavior and improve patient adherence and self-management. The goal will be to
facilitate the adoption of these evidence-based practices in order to improve TTR in VISN 1.
The investigators will accomplish this through a two-part intervention: 1) A
clinician-focused intervention will utilize educational outreach, audit and feedback,
internal facilitation, and external facilitation to promote improvements in four
evidence-based processes of care. 2) A patient-focused intervention will utilize outreach, a
group educational seminar, and motivational interviewing to educate patients with poor
baseline anticoagulation control and promote behavior change.

Methods: The clinician-focused intervention will use a Dashboard to measure site-level TTR
and processes of care and an Algorithm for routine AC management. Both the Dashboard and the
Algorithm are concrete representations of our main evidence-based recommendations to improve
AC management. The investigators will promote their use through quarterly visits to the
sites, which will include audit and feedback and educational outreach, and also provide
external facilitation to address ways to improve these performance measures. The
patient-level intervention will be delivered to the 25% of VISN patients with low TTR at
baseline (<50%). ACC staff will identify such patients using the Dashboard, and will send
them an outreach letter inviting them to attend a brief educational seminar. All intervention
patients, whether or not they attended the seminar, will receive follow-up management
including motivational interviewing (MI) to address behavior change. The main outcome for Aim
1 is change in site TTR over time, which will be compared between VISN 1 and non-VISN 1 sites
using an interrupted time series. The main outcome for Aim 2 is change in patient-level TTR,
for which intervention and control patients will be compared using a regression discontinuity
analysis. Secondary outcomes will include site-level changes in processes of anticoagulation
care (measured using automated data), costs and cost savings, and sustainability of changes
over time.

Anticipated Impact: The goal of this project is to increase TTR in VISN 1 to 75%, far higher
than any other VISN. Such improvement in TTR is associated with greatly reduced rates of
adverse events for patients. Improved TTR will save more money than our intervention will
cost, in large part because of efficiencies of management and less-frequent follow-up for
better controlled patients. At the conclusion of this regional project, the investigators
will promote the spread of these interventions throughout the VHA.

Inclusion Criteria:

- All patients receiving long-term oral anticoagulation with warfarin within the VA New
England Region ("VISN 1")

Exclusion Criteria:

- Patients with valvular heart disease, who may have an INR target range other than 2-3.
This usually represents between 10-15% of patients receiving anticoagulation.