Impact of introducing anticoagulation-related prescribing guidelines in a hospital setting using academic detailing

Abstract

Aim: Assess the impact of using academic detailing-assisted guideline roll-out on warfarin initiation, reversal of warfarin overanticoagulation, and uptake of deep vein thrombosis (DVT) prophylaxis across 4 metropolitan teaching hospitals. Methods: Baseline data were collected for 3 months prior to intervention. Prescribers were then informed about the guidelines, including feedback of current hospital performance and the basis for the guidelines. Post-intervention data were collected for 3 months after guideline implementation. Results: Uptake of DVT prophylaxis in medical patients increased from 52.8% to 67.0% (p=0.004). No impact on operative surgical patients was seen, possibly due to the high preexisting rate of uptake (86.1% vs 84.1%, p=0.7). DVT prophylaxis rates in non-operative surgical patients were similar to medical patients, with similar, but non-significant improvements. The time to reach a stable therapeutic international normalized ratio (INR) after warfarin initiation was reduced (p=0.03) as were the number of INR's >4 in the first week of therapy (p=0.03). There were significant improvements in appropriate vitamin K use for warfarin overanticoagulation in patients with an INR above 6 (48% vs 74%, p=0.007), timely follow-up tests (49% vs 62%, p=0.009), and the proportion of next INR's being less than 4 (49% vs 61%, p=0.04). Conclusions:The use of academic detailing to facilitate guideline roll-out had a positive impact on nearly all areas studied. The academic detailing process within the hospital setting was received enthusiastically by prescribers.

Efficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titration

“…During the first week of warfarin initiation, the percentage of INRs of more than 4 were reported as 7% by Roberts et al. (10) and up to 32% by Roberts and Adams (11). The baseline cohort of this study at 27% could be contributed to by the fact that nomograms were not used, INRs were not necessarily checked daily and dosing was based more on individual INR readings without observing INR trends.…”

Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study

“…The study was designed to detect a change in prescribing practice of 15% (from 50% to 65% appropriate prophylaxis). This estimate of effect was based on two previous studies which had used EOVs to improve VTE prophylaxis in the acute care setting [ 25 , 26 ]. A total sample size of 300 patients (150 pre and 150 post intervention) was necessary to power the study at 80% with a significance level of 5%.…”

Testing the effect of a targeted intervention on nurses’ compliance with “best practice” mechanical venous thromboembolism prevention

“…Two more recent studies (9, 10) have used EOVs as a strategy to increase compliance with VTE prevention guidelines among doctors in the hospital setting. Roberts and Adams's study (9) showed an increase of 14.2% (p=0.004) in guideline adherence for medical patients from a baseline of 52.8%. Grupper et al (10) reported a 21% (p<0.001) increase in VTE guideline compliance for surgical patients using EOVs.…”