Background: Anticoagulation therapy with warfarin often requires frequent communication between patients and their anticoagulation providers. Providers communicate the current dose schedule, INR/PT lab results, schedule the next blood draws, and ask for updates in patient status such as new medications, changes in health, diet, or activity. Currently, these interactions take place mostly in the form of phone calls and voicemails from anticoagulation nurses to their patients. With the widespread adoption of new telecommunications technology, there is an opportunity to leverage the capabilities of mobile devices to facilitate communication between patients and their providers in order to enhance patient engagement and support clinical care goals. Methods: To assess the current use of technology among warfarin patients and the potential utilization of mobile devices in anticoagulant therapy, we surveyed 136 patients from two sites of the MAQI2 consortium. Survey questions investigated the use of technology for health information and comfort using mobile devices in this cohort of patients. The survey asked whether patients undergoing warfarin therapy believe a mobile device, a smartphone/tablet, would be useful to support instructions. Responses were linked to each patient’s health record by their MAQI2 ID to characterize them based on demographics and indicators of quality of care such as time in therapeutic range (TTR) and the number of out of range INRs. Results: The survey results show that 84% of patients who responded to the survey have internet connectivity at their home. In addition, 66% reported that they always or sometimes use a computer to find health information compared with 34% who rarely or never go online seeking health information (p<0.01). Patients who are comfortable with mobile devices are on average 14 years younger, 57 vs. 71 years old (p<0.01). About 70% of patients responded that a mobile device would be useful to support warfarin instruction and 44% of these patients responded that they would be capable of using a device to support their warfarin therapy. These patients that responded favorably to mobile devices have a lower TTR 40.6% vs. 64.2% (p<0.01), and almost twice the rate of out of range INRs with known reasons (p>0.05) for example such as a change in medication, diet, or because the patient took more/less warfarin than prescribed. Conclusion: A majority of warfarin patients surveyed have internet connectivity at home, and they currently use a computer for health-related purposes. Patients who are most likely to use a mobile device to support instructions and communicate with their providers are younger and spend less time in therapeutic range. Quality of care may be improved in this population through an online/mobile application as a resource to communicate dose changes, remind patients of scheduled blood draws, and collect changes in patient status.
Patients on chronic warfarin therapy require regular laboratory monitoring to safely manage warfarin. Recent studies have challenged the need for routine monthly blood draws in the most stable warfarin-treated patients, suggesting the safety of less frequent laboratory testing (up to every 12 weeks). De-implementation efforts aim to reduce the use of low-value clinical practices. To explore barriers and facilitators of a de-implementation effort to reduce the use of frequent laboratory tests for patients with stable warfarin management in nurse/pharmacist-run anticoagulation clinics, we performed a mixed-methods study conducted within a state-wide collaborative quality improvement collaborative. Using a mixed-methods approach, we conducted post-implementation semi-structured interviews with a total of eight anticoagulation nurse or pharmacist staff members at five participating clinic sites to assess barriers and facilitators to de-implementing frequent international normalized ratio (INR) laboratory testing among patients with stable warfarin control. Interview guides were based on the Tailored Implementation for Chronic Disease (TICD) framework. Informed by interview themes, a survey was developed and administered to all anticoagulation clinical staff (n = 62) about their self-reported utilization of less frequent INR testing and specific barriers to de-implementing the standard (more frequent) INR testing practice. From the interviews, four themes emerged congruent with TICD domains: (1) staff overestimating their actual use of less frequent INR testing (individual health professional factors), (2) barriers to appropriate patient engagement (incentives and resources), (3) broad support for an electronic medical record flag to identify potentially eligible patients (incentives and resources), and (4) the importance of personalized nurse/pharmacist feedback (individual health professional factors). In the survey (65% response rate), staff report offering less frequent INR testing to 56% (46–66%) of eligible patients. Most survey responders (n = 24; 60%) agreed that an eligibility flag in the electronic medical record would be very helpful. Twenty-four (60%) respondents agreed that periodic, personalized feedback on use of less frequent INR testing would also be helpful. Leveraging information system notifications, reducing additional work load burden for participating patients and providers, and providing personalized feedback are strategies that may improve adoption and utilization new policies in anticoagulation clinics that focus on de-implementation.
