Quality metrics of warfarin initiation in hospitalized older adults
- 48 Downloads
Achieving therapeutic international normalized ratio (INRs) in warfarin naïve older adults can be complicated due to sensitivity factors. While multiple tools exist for warfarin initiation in the outpatient setting, there is a dearth of guidance for inpatient initiation. This study aims to: (1) describe a large health system’s initiation warfarin quality metrics in older inpatients, defined by INR overshoots greater than or equal to 5.0; (2) identify intrinsic and extrinsic patient factors associated with overshoots; and (3) explore the association between inpatient overshoots and clinical outcomes. Data on inpatients ≥ 65 years initiated on warfarin 1/1/2014-6/30/2016 were extracted through retrospective chart review. The primary outcome was prevalence of overshoots (INR ≥ 5). Logistic regression modeling determined the risk factors for overshoots. Multivariate analysis was employed to associate overshoots with length of stay (LOS), bleeding, and mortality. Additional analysis of the impact of patient weight (kg) on overshoots was achieved through chi square analysis. Of 4556 inpatients initiated on warfarin, 8% experienced overshoots. Non-black race, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), mild liver disease, low weight, and no statin use were found to be predictive of overshoots. Compared to the group without overshoots, the group with overshoots experienced a significantly increased LOS (13 days vs. 8 days, < 0.001), higher bleed rate (30.1% vs. 6.5%, adjusted OR 6.2, p < 0.001), and higher mortality rate (13.8% vs. 3.4%, adjusted OR 4.4, p < 0.001). Inpatient warfarin initiation was associated with frequent overshoots and poor outcomes. Future studies should focus on strategies to improve hospital warfarin initiation safety.
KeywordsAdverse drug events Anticoagulants Inpatients INR Warfarin Warfarin initiation
The authors would like to acknowledge the New York State Empire Clinical Research Investigator Program (ECRIP) and the Center for Health Innovations and Outcomes Research at Northwell Health for their support.
Compliance with ethical standards
Conflict of interest
The authors have no conflicts of interest to report. All authors confirm that they have had full access to data and contributed to drafting of the paper.
- 7.Ghate SR, Biskupiak J, Ye X, Kwong WJ, Brixner DI (2011) All-cause and bleeding-related health care costs in warfarin-treated patients with atrial fibrillation. J Manag Care Pharm 17(9):672–684Google Scholar
- 8.National Patient Safety Goals.03.05.01 [Internet]. joint Commission. https://www.jointcommission.org/assets/1/6/2017_NPSG_HAP_ER.pdf. Accessed 25 Aug 2017
- 9.Garcia DA, Schwartz MJ (2011) Warfarin therapy: tips and tools for better control: monitoring patients on warfarin therapy is challenging. The tools highlighted here–from online forums and web-based dosing calculators to patient education materials and self-monitors–can help. J Fam Pract 60(2):70–76Google Scholar
- 13.Sharma M, Krishnamurthy M, Snyder R, Mauro J (2017) Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care. Clin Pract 7(2):953Google Scholar