Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients
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Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing.
A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review.
Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious.
There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.
KeywordsPrescribing Medication safety Patient safety Systematic review Anticoagulants
The authors greatly appreciate the assistance of Sue Sacre and Jasmin Monaghan (Graphic Designers at Clinical Multimedia, The Royal Brisbane and Women’s Hospital) with reformatting of images for publication.
All authors have made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data. All were involved with drafting the work or revising it critically for important intellectual content and have given final approval of the version published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Compliance with ethical standards
The authors declare that they have no competing interest.
- 15.The Joint Commission (2019) National Patient Safety Goals Effective January 2019: Hospital Accreditation Program. https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf. Accessed 12 Jan 2019
- 16.ACSQHC (2018)Australian Commission on Safety and Quality in Health Care: Annual Report 2017–2018. https://www.safetyandquality.gov.au/wp-content/uploads/2018/10/ACSQHC_Annual_Report_2017-2018.pdf. Accessed 12 Jan 2019
- 20.Tran H, Joseph J, Young L, McRae S, Curnow J, Nandurkar H, Wood P, McLintock C (2014) New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. Australasian Society of Thrombosis and Haemostasis. Intern Med J 44(6):525–536CrossRefGoogle Scholar
- 22.Witt DM, Clark NP, Kaatz S, Schnurr T, Ansell JE Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism. J Thromb Thrombolysis 41(1):187–205Google Scholar
- 26.Bradley G (1998) An audit of anticoagulant guidelines: the relative influence of education, presentation and complexity of guidelines on compliance. J Clin Eff 3(2):84–89Google Scholar
- 29.Enriquez JR, de Lemos JA, Parikh SV, Simon DN, Thomas LE, Wang TY et al Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes: Results From the National Cardiovascular Data Registry. Circ Cardiovasc Qual Outcomes 8(6):576–585Google Scholar
- 33.United Nations (2018) World economic situation and prospects 2018, UN, New York https://www.un.org/development/desa/dpad/wp-content/uploads/sites/45/publication/WESP2018_Full_Web-1.pdf. Accessed 6 July 2019
- 34.Cochrane Effective Practice and Organisation of Care group (2017) What study designs can be considered for inclusion in an EPOC review and what should they be called? EPOC resources for review authors. Norwegian Knowledge Centre for the Health Services. http://epoc.cochrane.org/resources/epoc-resources-review-authors. Accessed 12 Jan 2019
- 35.Cochrane Effective Practice and Organisation of Care group (2013) Data collection form. EPOC Resources for review authors. Norwegian Knowledge Centre for the Health Services. http://epoc.cochrane.org/epoc-specific-resources-review-authors. Accessed 12 Jan 2019
- 36.Cochrane Effective Practice and Organisation of Care group (2017) Suggested risk of bias criteria for EPOC reviews. EPOC Resources for review authors. Norwegian Knowledge Centre for the Health Services. http://epoc.cochrane.org/resources/epoc-resources-review-authors. Accessed 12 Jan 2019
- 37.Cochrane Collaboration (2014) Review Manager (RevMan) [Computer program]. Version 5.3. The Nordic Cochrane Centre, CopenhagenGoogle Scholar
- 38.Higgins JPT, Green S (editors) (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration www.handbook.cochrane.org. Accessed 12 Jan 2019
- 39.Chenella FC, Klotz TA, Gill MA (1983) Comparison of physician and pharmacist management of anticoagulant therapy of inpatients. Am J Hosp Pharm 40(10):1642–1645Google Scholar
- 42.Carter BL, Taylor JW, Becker A (1987) Evaluation of three dosage-prediction methods for initial in-hospital stabilization of warfarin therapy. Clin Pharm 6(1):37–45Google Scholar
- 43.Kimmel SE, French B, Kasner SE, Johnson JA, Anderson JL, Gage BF, Rosenberg YD, Eby CS, Madigan RA, McBane R, Abdel-Rahman SZ, Stevens SM, Yale S, Mohler ER III, Fang MC, Shah V, Horenstein RB, Limdi NA, Muldowney JA III, Gujral J, Delafontaine P, Desnick RJ, Ortel TL, Billett HH, Pendleton RC, Geller NL, Halperin JL, Goldhaber SZ, Caldwell MD, Califf RM, Ellenberg JH, COAG Investigators (2013) A pharmacogenetic versus a clinical algorithm for warfarin dosing. N Engl J Med 369(24):2283–2293CrossRefGoogle Scholar
- 45.Ovesen L, Lyduch S, Ott P (1989) A simple technique for predicting maintenance dosage of warfarin - is it better than empirical dosing? Eur J Clin Pharmacol 37(6):573–576Google Scholar
- 48.Becker R, Ball S, Eisenberg P, Borzak S, Held A, Spencer F et al (1999) A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease. Antithrombotic therapy consortium investigators. Am Heart J 137(1):59–71CrossRefGoogle Scholar
- 52.Strom BL, Schinnar R, Bilker W, Hennessy S, Leonard CE, Pifer E (2010) Randomized clinical trial of a customized electronic alert requiring an affirmative response compared to a control group receiving a commercial passive CPOE alert: NSAID--warfarin co-prescribing as a test case. J Am Med Inform Assoc 17(4):411–415CrossRefGoogle Scholar
- 57.Hayes R, Bratzler D, Armour B, Moore L, Murray C, Stevens BR, Radford M, Fitzgerald D, Elward K, Ballard DJ (2001) Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis. Jt Comm J Qual Improv 27(3):155–168Google Scholar
- 58.Middeldorp S, Prins MH, Hutten BA (2014) Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism. Cochrane Database Syst Rev 8:CD001367Google Scholar
- 62.Pawloski SJ, Kersh PL (1992) Therapeutic heparin monitoring service in a small community hospital. Hosp Pharm 27(8):703–706 23Google Scholar
- 63.Bloomfield HE, Taylor BC, Krause A, Reddy P, Greer N, MacDonald R et al (2011) Safe and effective anticoagulation in the outpatient setting: a systematic review of the evidence. United States Department of Veteran Affairs, Washington DC. https://www.ncbi.nlm.nih.gov/books/NBK54599/. Accessed 14 Jan 2019
- 64.Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E et al (2017) Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2:CD003543Google Scholar
- 68.Nuckols TK, Smith-Spangler C, Morton SC, Asch SM, Patel VM, Anderson LJ, Deichsel EL, Shekelle PG (2014) The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev 3:56CrossRefGoogle Scholar
- 71.Slikkerveer M, van de Plas A, Driessen JHM, Wijngaard R, de Vries F, Olie R et al (2017) Prescribing errors with low-molecular-weight heparins. J Patient Saf. https://doi.org/10.1097/PTS.0000000000000417
- 74.Steinberg BA, Shrader P, Pieper K, Thomas L, Allen LA, Ansell J et al (2018) Frequency and outcomes of reduced dose non-vitamin K antagonist anticoagulants: results from ORBIT-AF II (the outcomes registry for better informed treatment of atrial fibrillation II). J Am Heart Assoc 7(4):e007633CrossRefGoogle Scholar