warfarin survey

Massachusetts Medical Society, Health Policy/Health Systems

1

Warfarin Survey

November 2007


2

Study Sponsors

Massachusetts Medical Society Massachusetts Coalition for the Prevention of

Medical Errors Massachusetts Association of Health Plans


3

Purpose

The specific goals of the study are to determine: 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.


4

Methodology

Sample Criteria 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


5

1. Roughly how many outpatients do you have on Warfarin at any one time?

7.1%

20.9%

33.5%

38.5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

None 1-10 11-30 >30 (please estimate thenumber of patients)

Median # of patients = 50

n=182


6

2. For which clinical indications do you have patients in your practice on Warfarin?

92% 95%88%

71%77%

65%71%

8% 5%12%

29%23%

35%29%

138

107

84

29 25 2518

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Chronic orparoxysmal atrial

fibrilation (AF)(n=167)

Deep VeinThrombosis

(DVT) orPulmonary

Embolus (PE)(n=165)

Mechanical heartvalve (n=153)

Post total hip orknee surgery

(n=139)

HypercoagulableCondition (n=135)

History of strokeor Transient

Ischemic Attack(TIA) without

documented AF(n=129)

ChronicCongestive Heart

Failure (CHF)with a low

ejection fraction(n=123)

% R

espo

nses

(Y

es/N

o)

0

20

40

60

80

100

120

140

160

# of

Res

pons

es T

hree

Mos

t Com

mon

Indi

catio

ns

Yes No 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?

8.1%5.8%

9.3%

40.7%

36.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

None Up to a third Between a third an twothirds

Between two thirds and95%

Almost all (i.e., >95%)

n=172


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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?

6.6%

29.4%

48.6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

In thier home (n=122) In your office (n=121) In the lab you use (n=140)

Me

an

%


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5. Do you use an anticoagulation monitoring and managing service (AMMS)?

44.1%

55.9%

0%

10%

20%

30%

40%

50%

60%

Yes No

n=177


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6. If you answered “yes” to question #5, does your AMMS include:

81.9% 82.9% 78.7%100.0%

79.7%90.7%

80.0%

18.1% 17.1% 21.3% 20.3%9.3%

20.0%

0%10%20%30%40%50%60%70%80%90%

100%

A registry of yourpatients who areon Warfarin andenrolled in theAMMS (n=72)

A written set ofguidelines (n=76)

A definedprogram of

patient education(n=75)

Specification ofthe targeted INRrange for eachpatient (n=75)

An algorithm fordose adjustmentsto be made whenthe INR is outside

the targetdtherapuetic range

(n=74)

Follow-up phonecalls by a nurse,

physicianassistant (PA), orpharmacist when

the patient isoverdue for anINR test or theINR result isoutside the

targeted

Communicationto you of INR test

results, dosechanges made,

timing of next INRtest, etc. (n=75)

Yes No


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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.

48% 44%

7%

71%

3%

48%

27%

5%11%

23%

3%0%

10%20%30%40%50%60%70%80%90%

100%

Very low riskfor a

thromboticstroke (n=43)

Too high arisk or

intracranialbleeding(n=89)

History of GIbleed (n=81)

Too old(please

specify agelimit) (n=13)

History or riskof falls

(n=132)

Lives alone(n=5)

History of poorcompliance

(n=89)

Dementia(n=50)

On othermedications,one or more

known tointeract with

Warfarin(n=10)

My previousexperience

with seriousWarfarin

complications(n=5)

Other (pleasespecify)(n=21)

% o

f R

esp

on

den

ts

0

20

40

60

80

100

120

140

# o

f R

esp

on

ses

% of Responses # 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

>80 (1), 85 (3), 88 (1), 90 (3), 92 (1), 95 (2)


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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)

4%5%

4%3%

12%

0

5

10

15

20

25

I do not have access toan AMMS (n=23)

I cannot manage thetime consuming

activities required tosafely manage a

patient on Warfarin(n=6)

I do not want to refermy patients to the

AMMS that isavailable to mypractice (n=8)

Limitations in thirdparty coverage for theAMMS, specifically the

phone calls by thenurse, PA or

pharmacist (n=9)

Limitations in thirdparty coverage for theAMMS, specifically for

my services (n=7)

# o

f Re

spo

nse

s

0%

2%

4%

6%

8%

10%

12%

14%

% o

f Re

spo

nd

en

ts

# 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?

56% 62%46% 46%

72% 75% 67%54%

85%

44% 38%54% 54%

28% 25% 33%46%

15%

0%10%20%30%40%50%60%70%80%90%

100%

Educationalprogramsabout the

indicationsfor, risks andbenefits of,long termWarfarin(n=159)

Opportunityto learn fromrespectedcolleagues

about current"best

practices"(n=156)

Identificationof an AMMSin my region

(n=152)

How toestablish anAMMS in my

office(n=151)

Work withpayors toimprove

coverage forAMMS(n=162)


coverage forPOC INR

testing in thehome

(n=159)


coverage forPOC INR in

my office(n=161)


coverage forPOC INR

testing in thelab I use(n=149)


coverage formy services

(n=156)

Yes No

warfarin survey

Documents

health policyhealth

health policyhealth

warfarin surveynovember

service ammsthe barriers

estimated number of

ammsthe steps

use of amms

number of patients38