Improving management of atrial fibrillation and anticoagulation in a community hospital

Clinical trials have established the safety and efficacy of warfarin anticoagulation for stroke prevention in patients with atrial fibrillation. Other studies have documented patterns of underutilization and suboptimal warfarin therapy; physician underuse of warfarin may reflect the demands associated with monitoring the drug's effects. BASELINE STUDY: At Carney Hospital, a 230-bed acute care community teaching hospital in Boston, a retrospective chart review indicated that between July 1, 1995, and June 30, 1996, of 465 patients admitted with atrial fibrillation, 209 (45%) patients were discharged with warfarin therapy: 198 were receiving warfarin at admission, and 11 began therapy during hospitalization. Analysis of the admission international normalized ratios (INRs) indicated that a minority of patients on warfarin were safely anticoagulated at the time of admission. DESIGNING THE INTERVENTION: An anticoagulation clinic was established in fall 1997 to increase utilization of warfarin, standardize anticoagulation practices, and minimize physician time and effort needed to ensure safe anticoagulation. In early 1998 monitoring of hospitalized patients with chronic atrial fibrillation began.

The proportion of patients receiving warfarin therapy at admission increased from 46% in February-May 1998 to 63% in April-June 1999. Between October 1997 and July 1998, 49.1% of the 2,738 patient visits to the anticoagulation clinic showed an INR in the desired range. For the 2,238 visits during January through August 1999, 53.7% of the INRs were in the desired range.

Establishment of a clinic to oversee warfarin therapy and dissemination of indications for anticoagulation in patients with atrial fibrillation were followed by increases in the frequency of warfarin use in hospital patients and the incidence of safe therapy in ambulatory patients.