Patient-Level Determinants of Oral Anticoagulation Control in the VHA

VHA 中口服抗凝控制的患者水平决定因素

• 批准号: 8292944
• 负责人: ADAM J. ROSE
• 金额: --
• 依托单位: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-01-01 至 2013-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8292944
• 关键词: Accounting; Address; Adverse event; Alcohol abuse; Anticoagulants; Anticoagulation; Blood Clot; Blood coagulation; Caring; Case Mixes; Characteristics; Clinic; Clinical; Data; Ensure; Feedback; Guidelines; Hemorrhage; Hospitalization; Individual; Intervention; Leadership; Learning; Malignant Neoplasms; Measurement; Measures; Medical center; Medicare; Mental Health; Modeling; Monitor; Oral; Outpatients; Pathway interactions; Patients; Performance; Pharmaceutical Preparations; Policies; Process; Process Measure; Quality of Care; Race; Recommendation; Reporting; Research; Risk; Risk Adjustment; Safety; Severities; Site; Stroke; Testing; Therapeutic; Thromboembolism; Time; Variant; Venous; Veterans; Warfarin; Work; base; follow-up; improved; performance site; physical conditioning; prevent; tool

DESCRIPTION (provided by applicant): BACKGROUND Over 100,000 VHA patients receive oral anticoagulation therapy (OAT) each year. It is known that OAT is safer and more effective when patients spend a more time in the therapeutic range (TTR). However, VHA sites of care vary widely on TTR, from 70% time in range (excellent control) to below 40% (poor control). Our previous efforts to adjust TTR for case mix have had certain limitations, and we need to know more about what sites might do to improve their TTR. OBJECTIVES 1) Improve our risk adjustment model for TTR 2) Study the relationship between site-level processes of care and site-level performance on risk-adjusted TTR (RA-TTR) 3) Develop and pilot a tool to report each site's performance and opportunities for improvement. METHODS We will include all patients who received OAT from the VHA during the study period. We will compute TTR for each patient and mean TTR for each site of care. Aim 1) We will improve our risk adjustment model by adding severity levels to comorbid conditions. We hypothesize that more severe manifestations of comorbid conditions will have a greater impact on TTR. We will also improve our model by using VA-Medicare data to improve the accuracy of patient race, date of warfarin inception, and hospitalizations. It is important to accurately know the date of warfarin inception, because control improves over time for each individual patient. Hospitalizations are known to perturb anticoagulation control; we will disregard anticoagulation testing for 14 days after any VA or non-VA hospitalization. Aim 2) We will study the impact of five process measures on site-level anticoagulation control. Three of these measures relate to the site mean follow-up interval after a low (d1.5), in-range (2-3), or high (e4.0) INR test. One measure relates to the site mean INR value, which reflects whether the site systematically targets an INR of 2.5 (as per clinical guidelines) or tends to "shade" them lower or higher. The final measure relates to the proportion of patients receiving substantial monitoring of anticoagulation both inside and outside the VHA. We hypothesize that the ideal follow-up times to improve site-level TTR will be less than 28 days after an in-range value and less than 7 days after an extreme value. We hypothesize that sites with a mean INR at or near 2.50 and that sites with little or no co-management with non-VA clinicians will have the best control. Aim 3) We will develop and pilot a report for each site that summarizes the site's current performance on RA-TTR and the expected improvement from various changes in the process measures from Aim 2. We will pilot test these reports with VA clinical leadership to solicit feedback from end users. We hypothesize that each site will have a unique pathway to quality improvement. ANTICIPATED IMPACT Improving the anticoagulation control in the VHA could prevent thousands of adverse events each year, but quality improvement must begin with accurate quality measurement. Our improved risk-adjustment model will ensure that sites treating challenging patients are not penalized. In addition, we will learn important lessons about the impact of comorbid conditions on anticoagulation control, including alcohol abuse, cancer, and mental health conditions. This project will provide the first empirical evidence regarding ideal follow-up intervals in the management of anticoagulation, and will relate these to changes in performance by site. We will detail the impact of care fragmentation between VA and non-VA care upon anticoagulation control, an important safety issue for VA patients. Finally, we will develop and pilot a tool to communicate our recommendations for quality improvement to each site. This tool will eventually serve as the basis for a project to improve anticoagulation care throughout the VHA.

描述（由申请人提供）： 每年有超过100,000名VHA患者接受口服抗凝治疗（OAT）。众所周知，当患者在治疗范围（TTR）上花费更多的时间时，燕麦更安全，更有效。但是，TTR的VHA护理位点不等，从70％的时间（良好的对照）到低于40％（对照差）。我们以前的调整TTR的案例混合物的努力有一定的局限性，我们需要更多地了解站点可以采取哪些措施来改善其TTR。目标1）改善我们的TTR风险调整模型2）研究现场护理过程与风险调整后的TTR（RA-TTR）的现场级别绩效之间的关系（3）3）开发和试行一种工具来报告每个站点的绩效和改进的机会。方法我们将包括在研究期间从VHA接收燕麦的所有患者。我们将为每个患者计算TTR，并为每个护理部位计算平均TTR。目标1）我们将通过在合并症的情况下增加严重程度来改善风险调整模型。我们假设合并症的更严重的表现将对TTR产生更大的影响。我们还将通过使用VA-MeDicare数据来提高患者竞赛的准确性，华法林的成立日期和住院的准确性，从而改善我们的模型。准确地了解华法林的日期很重要，因为每个患者的控制会随着时间的流逝而改善。已知住院治疗可扰动抗凝治疗；在任何VA或非VA住院后，我们将无视抗凝测试14天。目标2）我们将研究五种过程测量对现场级抗凝控制的影响。这些措施中的三个与位点平均随访间隔有关，低（D1.5），范围内（2-3）或高（E4.0）INR测试。一项措施与位点平均INR值有关，该措施反映了该站点是系统地靶向2.5（按照临床指南）还是倾向于将其“阴影”降低或更高。最终措施与VHA内部和外部接受大量监测的抗凝治疗的患者的比例有关。我们假设，改善站点级TTR的理想随访时间将在范围内值后不到28天，而极值后不到7天。我们假设具有平均INR或接近2.50的地点，并且与非VA临床医生共同管理或没有共同管理的地点将具有最佳的控制。目标3）我们将为每个站点开发并试行一个报告，总结了该网站在RA-TTR上的当前表现以及AIM 2的各种过程变化的预期改进。我们将与VA Clinical Leadersition试用这些报告，以征求最终用户的反馈。我们假设每个站点都有独特的质量改进途径。预期的影响改善VHA中抗凝控制的影响可能每年可以防止数千个不良事件，但是质量的提高必须从准确的质量测量开始。我们改善的风险调整模型将确保治疗具有挑战性的患者的网站不会受到惩罚。此外，我们将学习有关合并症对抗凝控制的影响，包括酗酒，癌症和心理健康状况的重要课程。该项目将提供有关抗凝治疗管理理想随访间隔的第一个经验证据，并将这些证据与逐场绩效变化有关。我们将详细介绍VA和非VA护理对抗凝控制的护理碎片化的影响，这是VA患者的重要安全问题。最后，我们将开发并试行一种工具，以传达我们对每个站点的质量改进建议的建议。该工具最终将成为改善整个VHA抗凝护理项目的项目的基础。