Transcript Warfarin Survey - Massachusetts Coalition for the Prevention of

Warfarin Survey
November 2007
Massachusetts Medical Society, Health
Policy/Health Systems
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Study Sponsors



Massachusetts Medical Society
Massachusetts Coalition for the Prevention of
Medical Errors
Massachusetts Association of Health Plans
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Purpose
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The specific goals of the study are to determine:
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
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
the extent to which physicians prescribing Warfarin are, or
are not, using an Anticoagulation Monitoring and Managing
Service (AMMS)
the barriers to the use of an AMMS
the steps that physicians believe would be most likely to
remove barriers and promote the use of AMMS, and
the extent to which point of care (POC) international
normalized ratio (INR) testing is being used.
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Methodology
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Sample Criteria
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Full and Active License with a Massachusetts address
Seven Specialties
 Cardiology
 Family Medicine
 Geriatrics
 Internal Medicine
 Neurology
 Oncology
 Orthopedics
E-mail address within the MMS IMIS database
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1. Roughly how many outpatients do you have on
Warfarin at any one time?
Median # of
patients = 50
50%
45%
38.5%
40%
33.5%
35%
30%
25%
20.9%
20%
15%
10%
7.1%
5%
0%
None
n=182
1-10
11-30
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>30 (please estimate the
number of patients)
5
100%
% Responses (Yes/No)
90%
160
95%
92%
88%
138
140
77%
80%
71%
71%
70%
120
65%
107
100
60%
84
50%
80
35%
40%
29%
30%
23%
20%
10%
29%
8%
12%
5%
29
25
60
40
25
18
20
0
0%
Chronic or
paroxysmal atrial
fibrilation (AF)
(n=167)
Deep Vein
Thrombosis
(DVT) or
Pulmonary
Embolus (PE)
(n=165)
Yes
Chronic
Mechanical heart Post total hip or Hypercoagulable History of stroke
knee surgery Condition (n=135) or Transient Congestive Heart
valve (n=153)
Ischemic Attack Failure (CHF)
(n=139)
with a low
(TIA) without
documented AF ejection fraction
(n=123)
(n=129)
No
# of Responses Three Most Common Indications
2. For which clinical indications do you have patients in
your practice on Warfarin?
Three Most Common Indications (# of Responses)
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3. Roughly what percent of the patients you manage who
have chronic or paroxysmal AF do you maintain on long
term Warfarin?
50%
45%
40.7%
40%
36.0%
35%
30%
25%
20%
15%
10%
9.3%
8.1%
5.8%
5%
0%
None
n=172
Up to a third
Between a third an two
thirds
Between two thirds and
95%
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Almost all (i.e., >95%)
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4. Of the patients you have on long term Warfarin,
roughly what percentage of your patients use Point of
Care (POC) INR testing for measuring their INR?
48.6%
50%
45%
40%
35%
29.4%
Mean %
30%
25%
20%
15%
10%
6.6%
5%
0%
In thier home (n=122)
In your office (n=121)
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In the lab you use (n=140)
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5. Do you use an anticoagulation monitoring and
managing service (AMMS)?
60%
55.9%
50%
44.1%
40%
30%
20%
10%
0%
No
Yes
n=177
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6. If you answered “yes” to question #5, does your AMMS
include:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
18.1%
17.1%
21.3%
81.9%
82.9%
78.7%
20.3%
100.0%
79.7%
A registry of your A written set of
A defined
Specification of An algorithm for
patients who are guidelines (n=76)
program of
the targeted INR dose adjustments
on Warfarin and
patient education range for each to be made when
enrolled in the
(n=75)
patient (n=75) the INR is outside
AMMS (n=72)
the targetd
therapuetic range
(n=74)
Yes
9.3%
90.7%
20.0%
80.0%
Follow-up phone Communication
calls by a nurse, to you of INR test
physician
results, dose
assistant (PA), or changes made,
pharmacist when timing of next INR
the patient is
test, etc. (n=75)
overdue for an
INR test or the
INR result is
outside the
targeted
No
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100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
140
120
71%
100
48%
48%
44%
80
60
27%
23%
7%
5%
3%
11%
3%
40
# of Responses
% of Respondents
7. When you decide not to place a patient with chronic or
paroxysmal atrial fibrillation on Warfarin, which patient
characteristics are most likely to lead you to that decision?
Please check the three most common reasons.
20
0
Very low risk Too high a
for a
risk or
thrombotic intracranial
stroke (n=43) bleeding
(n=89)
History of GI
bleed (n=81)
Too old
History or risk Lives alone History of poor Dementia
(please
of falls
(n=5)
compliance
(n=50)
specify age
(n=132)
(n=89)
limit) (n=13)
>80 (1), 85 (3), 88 (1),
90 (3), 92 (1), 95 (2)
% of Responses
On other
My previous Other (please
medications, experience
specify)
one or more with serious
(n=21)
known to
Warfarin
interact with complications
Warfarin
(n=5)
(n=10)
# of Responses
Alcohol abuse (3), DNA, History any kind of bleeding, pt refusal, I am a surgeon; not in
my bailiwick, I don't make these decisions, I only treat oncologic/hematologic problems,
Impossible phlebotomy, Informed consent, Laennec cirrhosis, chronic renal failure,
Ortho only, Patient declines, Pt refuses, Pt refuses despite info consent & 2nd opinion,
Pt strong preference, Recurrent GI bleeds, Refer back to PCP, Unable to have lab
access or medication adjustment, We do not manage PAF
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8. Which system issues are important factors when you
decide not to place a patient with chronic or paroxysmal
atrial fibrillation on Warfarin? (check all that apply)
25
14%
12%
# of Responses
10%
15
8%
6%
10
4%
5
3%
5%
4%
4%
% of Respondents
12%
20
2%
0
0%
I do not have access to I cannot manage the
an AMMS (n=23)
time consuming
activities required to
safely manage a
patient on Warfarin
(n=6)
I do not want to refer Limitations in third
Limitations in third
my patients to the party coverage for the party coverage for the
AMMS that is
AMMS, specifically theAMMS, specifically for
available to my
phone calls by the
my services (n=7)
practice (n=8)
nurse, PA or
pharmacist (n=9)
# of Responses
% of Responses
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9. What actions would you like to see MMS take to help
you manage the patients in your practice whom you want
to have on Warfarin?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
44%
56%
25%
28%
38%
54%
54%
75%
72%
62%
46%
15%
33%
46%
46%
85%
67%
54%
Educational Opportunity Identification
How to
Work with
Work with
Work with
Work with
Work with
programs
to learn from of an AMMS establish an
payors to
payors to
payors to
payors to
payors to
about the
respected
in my region AMMS in my
improve
improve
improve
improve
improve
indications
colleagues
(n=152)
office
coverage for coverage for coverage for coverage for coverage for
for, risks and about current
(n=151)
AMMS
POC INR
POC INR in
POC INR
my services
benefits of,
"best
(n=162)
testing in the
my office
testing in the
(n=156)
long term
practices"
home
(n=161)
lab I use
Warfarin
(n=156)
(n=159)
(n=149)
(n=159)
Yes
No
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