Quality Improvement Program Improves Time in Therapeutic Range for Hemodialysis Recipients Taking Warfarin

Studies have shown that achieving a time in therapeutic range (TTR) for warfarin of greater than 60% is associated with a lower risk of bleeding. However, many patients on hemodialysis (HD) do not achieve this target.

We audited TTR achievement at the in-center HD unit of our hospital in 2017 and found that only 40% of patients had achieved a TTR >60%. We aimed to improve the percentage of HD patients achieving target TTR within 2 years. We reported each patient's individualized trend in quarterly TTR to their primary warfarin prescriber as an audit-feedback report. These reports were generated, disseminated, and subsequently improved following a series of plan-do-study-act cycles. We then used statistical process control to assess for changes in the percentage of HD patients achieving target TTR over time.

In the primary analysis, 28 patients were included in the baseline period, and 46 were included in the intervention period. At baseline, the percentage of patients achieving a TTR >60% varied between 33% and 45% (mean ± SD, 40% ± 5%); post-intervention, this metric improved and varied between 52% and 71% (mean ± SD, 61% ± 8%). In time-series analysis, there was evidence of statistically significant variation between the 2 periods and evidence of sustained improvement.

A quality improvement program consisting of an audit-feedback report that raises awareness of the quality gap in TTR achievement can result in substantial improvement in the safe and efficacious administration of warfarin to patients receiving maintenance hemodialysis.