Improving Anticoagulation Control in VISN 1

改善 VISN 1 中的抗凝控制

• 批准号: 9077063
• 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: 2012
• 资助国家: 美国
• 起止时间: 2012-10-01 至 2016-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9077063
• 关键词: Active Sites; Address; Adoption; Adverse event; Algorithms; Anticoagulants; Anticoagulation; Behavior; Blood coagulation; Caring; Cessation of life; Characteristics; Clinic; Coagulation Process; Cost Savings; Data; Education and Outreach; Effectiveness; Evaluation; Event; Evidence based practice; Feedback; Goals; Hemorrhage; Intervention; Leadership; Letters; Measures; Methods; New England; Oral; Outcome; Outpatients; Patients; Pattern; Performance; Pharmaceutical Preparations; Pharmacists; Procedures; Process; Process Measure; Provider; Readiness; Risk; Risk Factors; Rosa; Safety; Self Management; Series; Site; Stroke; Stroke prevention; Structure; System; Therapeutic; Time; Veterans; Visit; Warfarin; Work; base; behavior change; compliance behavior; cost; evidence base; evidence based guidelines; follow-up; high risk; improved; innovation; interest; intervention effect; motivational enhancement therapy; novel; outreach; prevent; programs; public health relevance; quality assurance; secondary outcome

DESCRIPTION (provided by applicant): 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). We 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. We have further investigated the structures and processes of care that contribute to these wide disparities in TTR performance. Objectives: In this proposed study, we 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. We will accomplish this through a two-part intervention: 1) Our clinician-focused intervention will utilize educational outreach, audt and feedback, internal facilitation, and external facilitation to promote improvements in four evidence-based processes of care. 2) Our 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: Our 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. We will promote their use through quarterly visits to the sites, at which we will deliver audit and feedback and educational outreach, and also provide external facilitation to address ways to improve these performance measures. Our 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. Our 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. Our 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 Impacts: Through this project, we anticipate that TTR in VISN 1 will increase to 75%, far higher than any other VISN. Such improvement in TTR is associated with greatly reduced rates of adverse events for patients. We also anticipate that 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, we will promote the spread of these interventions throughout the VHA. We anticipate great interest in implementing a program which improves patient outcomes while saving money. PUBLIC HEALTH RELEVANCE: Over 100,000 VHA patients receive anticoagulants (blood thinners) each year to prevent blood clots (including strokes). Too much anticoagulation increases the risk of serious or even fatal bleeding, and too little anticoagulation fails to protect the patient against blood clots. VHA anticoagulation clinics vary widely on how much time their patients spend in the therapeutic range, the range within which they are protected from clots but not at excessive risk of bleeding. Anticoagulation clinics can improve anticoagulation control by following several relatively simple procedures, including following-up promptly when patients are out of range and focusing on educating and supporting patients with poor control. In this study, we will promote these practices at the anticoagulation clinics of the New England VA region, with a goal of improving anticoagulation control.

描述（由申请人提供）： 背景：每年有100,000多名VA患者接受口服抗凝治疗（AC），以防止血液凝块，包括中风。当AC巧妙地管理和控制良好时，AC更安全，更有效。可以使用治疗范围（TTR）的时间百分比来测量AC控制，这是患者充分抗凝以防止血栓但不会过度抗凝（这增加出血风险）的时间比例。我们已经表明，VA的抗凝诊所（ACC）在TTR上不等，从40％（非常差的对照）到70％（出色的对照）。改善VA中的TTR将防止成千上万的不良事件，包括中风，主要出血和死亡。我们进一步研究了导致TTR性能差异的巨大差异的护理结构和过程。目标：在这项拟议的研究中，我们将采用良好的方法来改变提供者的行为并改善患者的依从性和自我管理。目的是促进采用这些基于证据的实践，以改善VISN 1的TTR。我们将通过两部分的干预措施来实现这一点：1）我们以临床医生为中心的干预措施将利用教育外展，AUDT和反馈，内部促进，内部促进和外部促进，以在基于循证的护理过程中促进改进。 2）我们以患者为中心的干预措施将利用外展，小组教育研讨会以及动机访谈，以教育基线抗凝控制差的患者并促进行为改变。方法：我们以临床医生为中心的干预措施将使用仪表板来测量站点级的TTR和护理过程以及用于常规交流管理的算法。仪表板和算法都是我们基于证据的主要建议的具体表示，以改善AC管理。我们将通过季度访问对这些地点进行审计，反馈和教育外展活动的季度访问，并提供外部促进，以解决改善这些绩效措施的方法。我们的患者级干预将交付给基线下TTR低的25％的VISN患者（<50％）。 ACC员工将使用仪表板识别此类患者，并将向他们发送一封外展信，邀请他们参加简短的教育研讨会。所有干预患者，无论他们是否参加了研讨会，都将获得随访管理，包括动机面试（MI）以解决行为改变。 AIM 1的结果是随着时间的推移而变化的站点TTR的变化，这将使用中断的时间序列在VISN 1和非VISN 1站点之间进行比较。我们对AIM 2的结果是患者级TTR的变化，为此，将使用回归不连续分析比较干预和对照患者。次要结果将包括抗凝护理过程（使用自动数据测量），成本和成本节省以及随时间变化的可持续性的站点级别的变化。预期的影响：通过这个项目，我们预计VISN 1中的TTR将增加到75％，远高于任何其他VISN。 TTR的这种改善与患者的不良事件发生率大大降低有关。我们还预计，改善的TTR将节省比干预措施更多的钱，这在很大程度上是由于管理效率和对更好受控患者的频繁随访。在这个区域项目的结论中，我们将促进这些干预措施在整个VHA中的传播。我们预计实施一项计划，可以改善患者的成果，同时节省资金。 公共卫生相关性： 每年超过100,000名VHA患者接受抗凝剂（血液稀释剂），以防止血凝块（包括中风）。过多的抗凝治疗会增加严重甚至致命出血的风险，而太少的抗凝治疗无法保护患者免受血液凝结的侵害。 VHA抗凝诊所因患者在治疗范围内花费的时间而差异很大，该诊所的范围是保护凝块的范围，但没有过多的出血风险。抗凝诊所可以通过遵循几个相对简单的程序来改善抗凝控制，包括及时及时进行范围内的及时进行跟进，并专注于教育和支持控制不良的患者。在这项研究中，我们将在弗吉尼亚州新英格兰地区的抗凝诊所中促进这些实践，以改善抗凝控制。