May 21, 2010

Project aims to redefine management of warfarin

Project aims to redefine management of warfarin

Vanderbilt University Medical Center will draw on its strengths in clinical information technology and systems approaches to patient care to transform management of the commonly used oral anticoagulant warfarin.

The project falls under the Medical Center's new innovation pillar; VUMC organizational goals are set out under five management foci or pillars — quality, service, people, growth/finance and, new this year, innovation.
“Innovation is not about incremental, iterative improvement: it's about finding what we can do to change the game,” said Jack Starmer, M.D., M.M.H.C., chief quality informatics officer.

Some 30 million prescriptions for warfarin are written each year in the United States. The drug helps different types of patients avoid abnormal thrombosis (clotting) and associated embolism (blood vessel blockage).

Getting too much or too little warfarin can bring dangerous consequences; and because sensitivity to the drug varies considerably and certain foods and a number of commonly used medications interact with it, warfarin dosing is somewhat unpredictable. In one study, annual rates of severe bleeding among patients taking warfarin were between 0.9 and 2.7 percent; the worst of this is intracranial hemorrhage resulting in disability and death.

“It works out that having warfarin patients in correct range around 70 percent of the time is about as good as it gets; that's regarded as the best achievable result. And that's what we currently have at Vanderbilt. Our goal is to bring everyone within range at least 90 percent of the time,” Starmer said.

“Our goal is to dramatically increase in-range clotting values and to decrease the consequences of out-of-range values,” said anticoagulation expert Mike Laposata, M.D., Ph.D., professor of Pathology and Medicine. “This should mean fewer bleeding episodes due to high values and fewer thrombotic episodes due to low values.”

Within a new Anticoagulation Clinic, nurses at clinical workstations will form a consolidated telemedicine front line for outpatient warfarin management.

For exceptionally difficult cases, physicians who are expert at anticoagulation will rotate to provide telephone consults both to nurses at the clinic and to inpatient teams.

The heart of the innovation project is IT-supported surveillance and tailored management of warfarin patient subgroups.

Half of Vanderbilt patients on warfarin already stay within range 90 percent of the time. When patients fall out of range more often than that, it's assumed to be due to more or less distinct physiological and/or socio-behavioral causes, so a data analysis team is working to uncover these causes and stratify the warfarin population accordingly.

As subgroups are identified, warfarin management strategies will be tailored for each group — home testing kits, more frequent clinical or telemedicine contact, coaching of family members to assist medication administration, and so on. As new warfarin patients are enrolled in the clinic, the system will automatically size them up and place them in the appropriate management-subgroups.

Once success is in sight, the project will take up management of additional anticoagulants.

“It's bringing together the idea of informatics-based surveillance with personalized planning, leading to ever finer informatics surveillance so that we're able to individualize without always having to involve the human,” said Bill Stead, M.D., associate vice chancellor and chief strategy and information officer.

“There's a lot of power in consolidating the patient population: it's great for research and for learning what makes a positive difference for keeping a patient in range,” said Karla Davis, R.N., M.S.N., M.H.A., manager of the Anticoagulation Clinic.