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    INR targets and site-level anticoagulation control: results from the Veterans AffaiRs Study to Improve Anticoagulation (VARIA)

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    Authors
    Rose, Adam J.
    Berlowitz, Dan R.
    Miller, Donald R.
    Hylek, Elaine M.
    Ozonoff, Al
    Zhao, Shibei
    Reisman, Joel I.
    Ash, Arlene S.
    UMass Chan Affiliations
    Department of Quantitative Health Sciences
    Document Type
    Journal Article
    Publication Date
    2012-04-01
    Keywords
    Administration, Oral
    Aged
    Anticoagulants
    Blood Coagulation
    Drug Monitoring
    Female
    Guideline Adherence
    Healthcare Disparities
    Humans
    International Normalized Ratio
    Male
    Middle Aged
    Physician's Practice Patterns
    Practice Guidelines as Topic
    Predictive Value of Tests
    Quality Indicators, Health Care
    Time Factors
    United States
    United States Department of Veterans Affairs
    Cardiovascular Diseases
    Epidemiology
    Health Services Research
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    Link to Full Text
    http://dx.doi.org/10.1111/j.1538-7836.2012.04649.x
    Abstract
    BACKGROUND: Not all clinicians target the same International Normalized Ratio (INR) for patients with a guideline-recommended target range of 2-3. A patient's mean INR value suggests the INR that was actually targeted. We hypothesized that sites would vary by mean INR, and that sites of care with mean values nearest to 2.5 would achieve better anticoagulation control, as measured by per cent time in therapeutic range (TTR). OBJECTIVES: To examine variations among sites in mean INR and the relationship with anticoagulation control in an integrated system of care. PATIENTS/METHODS: We studied 103,897 patients receiving oral anticoagulation with an expected INR target between 2 and 3 at 100 Veterans Health Administration (VA) sites from 1 October 2006 to 30 September 2008. Key site-level variables were: proportion near 2.5 (that is, percentage of patients with mean INR between 2.3 and 2.7) and mean risk-adjusted TTR. RESULTS: Site mean INR ranged from 2.22 to 2.89; proportion near 2.5, from 30 to 64%. Sites' proportions of patients near 2.5, below 2.3 and above 2.7 were consistent from year to year. A 10 percentage point increase in the proportion near 2.5 predicted a 3.8 percentage point increase in risk-adjusted TTR (P < 0.001). CONCLUSIONS: Proportion of patients with mean INR near 2.5 is a site-level 'signature' of care and an implicit measure of targeted INR. This proportion varies by site and is strongly associated with site-level TTR. Our study suggests that sites wishing to improve TTR, and thereby improve patient outcomes, should avoid the explicit or implicit pursuit of non-standard INR targets.
    Source
    J Thromb Haemost. 2012 Apr;10(4):590-5. doi: 10.1111/j.1538-7836.2012.04649.x.
    DOI
    10.1111/j.1538-7836.2012.04649.x
    Permanent Link to this Item
    http://hdl.handle.net/20.500.14038/46654
    PubMed ID
    22288563
    Related Resources
    Link to article in PubMed
    ae974a485f413a2113503eed53cd6c53
    10.1111/j.1538-7836.2012.04649.x
    Scopus Count
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    Population and Quantitative Health Sciences Publications

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