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Original Research: Antithrombotic Therapy |

Gaps in Monitoring During Oral AnticoagulationGaps in Monitoring Oral Anticoagulation: Insights Into Care Transitions, Monitoring Barriers, and Medication Nonadherence

Adam J. Rose, MD; Donald R. Miller, ScD; Al Ozonoff, PhD; Dan R. Berlowitz, MD; Arlene S. Ash, PhD; Shibei Zhao, MPH; Joel I. Reisman, AB; Elaine M. Hylek, MD
Author and Funding Information

From the Center for Health Quality, Outcomes, and Economic Research (Drs Rose, Miller, Ozonoff, Berlowitz, Ash, and Hylek; Ms Zhao; and Mr Reisman), Bedford VA Medical Center, Bedford; the Department of Medicine (Drs Rose, Berlowitz, Ash, and Hylek), Section of General Internal Medicine, Boston University School of Medicine, Boston; the Department of Health Policy and Management (Drs Miller and Berlowitz), Boston University School of Public Health, Boston; the Biostatistics Section (Dr Ozonoff), Boston Children’s Hospital, Boston; and the Department of Quantitative Health Sciences (Dr Ash), Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, MA.

Correspondence to: Adam J. Rose, MD, Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Rd, Bldg 70, Bedford, MA 01730; e-mail: adamrose@bu.edu


Funding/Support: This project was supported by a grant from the Veterans Affairs Health Services Research and Development Service [IIR-10-374]. Dr Rose is supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Service [CDA-2-08-017].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(3):751-757. doi:10.1378/chest.12-1119
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Background:  Among patients receiving oral anticoagulation, a gap of > 56 days between international normalized ratio tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events.

Methods:  We studied long-term oral anticoagulation care for 56,490 patients aged 65 years and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percentage time in therapeutic range (TTR) at the 100 sites.

Results:  Many patients (45%) had at least one gap in monitoring during an average of 1.6 years of observation; 5% had two or more gaps per year. The median gap duration was 74 days (interquartile range, 62-107). The average TTR for patients with two or more gaps per year was 10 percentage points lower than for patients without gaps (P < .001). Patient-level predictors of gaps included nonwhite race, area poverty, greater distance from care, dementia, and major depression. Site-level gaps per patient-year varied from 0.19 to 1.78; each one-unit increase was associated with a 9.2 percentage point decrease in site-level TTR (P < .001).

Conclusions:  Site-level gap rates varied widely within an integrated care system. Sites with more gaps per patient-year had worse anticoagulation control. Strategies to address and reduce gaps in monitoring may improve anticoagulation control.

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