Warfarin Quality Metrics for Hospitalized Older Adults

Background  Warfarin's adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients. Objectives  We sought to describe a health system's chronic warfarin quality metrics in older inpatients, defined by international normalized ratio (INR) control, explore associations between INR overshoots and clinical outcomes, and identify factors associated with overshoots. Patients/Methods  Data on patients 65 years and older who were prescribed chronic warfarin and admitted during January 1, 2014, to June 30, 2016, were extracted through retrospective chart review. We defined overshoots as INRs 5 or greater after 48 hours of hospitalization. Logistic regression modeling was used to determine risks for overshoots and multivariate analysis for overshoots' association with length of stay (LOS), bleeding, and mortality. Results  Of the 12,107 older inpatients on chronic warfarin, most were 75 years or older (75.7%), female (51.2%), and white (70.0%). While 1,333 (11.0%) of patients had overshoots during the admission, 449 (33.7%) of these reached overshoots after 48 hours. When stratified by overshoots versus no overshoots, LOS more than doubled (15.6 vs. 6.8 days) and the bleed rate was significantly higher (27.4 vs. 8.3%) in the overshoot group. While overall mortality was small (0.4%), the overshoot group's mortality was significantly higher (3.12 vs. 0.28%). Black race and weight were protective against overshoots; history of heart failure and antibiotic/amiodarone exposure were predictive of overshoots. Conclusion  This is the largest study examining warfarin quality metrics for hospitalized adults, specifically older inpatients. Our model may serve as the basis for identifying high-risk warfarin patients to target interventions to reduce adverse drug events.