According to the Centers for Medicare and Medicaid Services and the American College of Chest Physicians, use and implementation of anticoagulation therapy in the United States is sub-optimal. Subspecialty anticoagulation clinics have shown improvements in patient outcomes, but are limited in number by expense and expertise requirements. We evaluated the quality and financial impact of an anticoagulation approach combining computerized decision support (CDS) and point of service (POS) testing in multiple primary care sites.
Cohort study, as a collaborative effort between the National Institutes of Health and the OSU Primary Care Research Institute.Participants: Test group (n=306) and control group (n=51) patients undergoing chronic anticoagulation therapy.Intervention: The test group was treated with POS testing and CDS. The control group was treated with a traditional anticoagulation approach (centralized laboratory testing, paper based record keeping, telephone contact).Outcome measures: 1.INR compliance defined by the ratio of therapeutic INR to total INR results; 2.Documentation of treatment indications and goal INR; 3.Clinic revenue generation; 4.Maintenance costs and costs due to treatment complications; 5.Clinic visit volume.
For the control group, INR compliance during baseline evaluation period was 38%. Test group INR compliance was significantly improved at 52%(p<0.01). Documentation of treatment indications and INR goal was 100% for test subjects, compared to 35% and 40% respectively for controls. Revenue production during a 2-year follow up totaled $270,977 from 5,692 encounters. Labor related overhead costs during this period dropped by 83%. Supply costs totaled $22,540. Estimated cost savings from complication avoidance amounted to $1,008,500. For every dollar spent on program implementation and operation, $20.41 was returned from revenue production, cost containment, and complication avoidance.
Utilizing POS testing and CDS to assist with anticoagulation therapy can improve INR compliance, reduce treatment costs and provide new sources of clinical revenue.
This anticoagulation approach improves quality of care, and is fiscally efficient enough to allow widespread use in both subspecialty and primary care settings.
Characteristics of Patients With Community Acquired VTE Versus Those With Hospital Acquired VTEDemographicCommunity Acquired VTE N = 295Hospital Acquired VTE N = 97p ValueMean age, yrs6166P<0.001Female (%)55.944.3P=0.05Race (%)White89.089.4Black4.52.1Hispanic2.86.3Other/unknown3.72.2P=NSRisk Factors for VTE*Other hospitalization last 3 mo.41.540.2P=NSRecent Immobility33.565.0P<0.001Recent Surgical Proceedures32.542.3P=NSRecent Infection22.755.7P<0.001Cancer30.928.9P=NSIschemic Heart Disease17.027.8P=0.02Recent Central Venous Catheter9.846.4P=<0.001Recent ICU Discharge8.045.3P<0.001Recent Intubation10.937.1P<0.001Recent Fracture15.916.5P=NSCongestive Heart Failure10.526.8P<0.001Previous DVT16.19.4P=NSCerebrovascular Disease11.219.6P=0.03Recent Hormonal Therapy14.97.2P=0.05Recent Chemotherapy10.98.2P=NSRecent Cardiac Procedures7.517.5P<0.01VTE prophylaxisDuring current hospital admissionAny VTE prophylaxisN/A85.6Any anticoagulant prophylaxisN/A56.7After recent surgeryN=95N=41Any VTE prophylaxis48.370.7P=NSAny anticoagulant prophylaxis35.853.7P=NSDuring prior hospitalizationN=119N=39Any VTE prophylaxis65.653.8P=NSAny anticoagulant prophylaxis47.146.2P=NSVTE typeDeep vein thrombosis85.485.6P=NSPulmonary embolism25.425.7P=NSBoth10.811.3P=NSHospital OutcomesRecurrent VTE0.33.1P<0.05Major Bleeding4.413.4P<0.01Mortality3.18.3P<0.05*
Only those with >10% prevalence displayed
Mark Wurster, Grant monies (from sources other than industry) National Institutes of Health