Outpatient Management of Oral Vitamin K Antagonist Therapy
Outpatient Management of Oral Vitamin K Antagonist Therapy
Oral anticoagulation therapy with warfarin is the mainstay of prevention and treatment of thromboembolic disease. However, it remains one of the leading causes of harmful medication errors and medication-related adverse events. The beneficial outcomes of oral anticoagulation therapy are directly dependent upon the quality of dose and anticoagulation management, but the literature is not robust with regards to what constitutes such management. This review focuses on, and attempts to define, the parameters of high-quality anticoagulation management and identifies the appropriate outcome measures constituting high-quality management. Elements discussed include the most fundamental measure, time in therapeutic range, along with other parameters including therapy initiation, time to therapeutic range, dosing management when patients are not in therapeutic range, perioperative dosing management, patient education, and other important outcome measures. Healthcare providers who manage oral anticoagulation therapy should utilize these parameters as a measure of their performance in an effort to achieve high-quality anticoagulation management.
Oral anticoagulation therapy with the vitamin K antagonists (VKA), particularly warfarin, which is the most commonly used VKA, continues to increase worldwide due to the aging population and its efficacy in preventing stroke in patients with atrial fibrillation or recurrent thromboembolism in patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Despite improved awareness of warfarin's efficacy and safety, the management of warfarin remains complex due to its intricate pharmacokinetic and pharmacodynamic properties and narrow therapeutic range. It is among one of the top five medications associated with drug errors that cause harm and has been shown to be one of the most common causes of emergency room visits due to an adverse event. National healthcare regulatory agencies have recently targeted anticoagulants, including warfarin, as high-risk medications and are focused on ensuring the safe use of these agents. One such agency, the Joint Commission, has proposed new 2008 National Patient Safety Goals aimed at minimizing the risks associated with warfarin use and reducing adverse events.
The beneficial outcomes of oral anticoagulation therapy are directly dependent upon achieving and maintaining an optimal international normalized ratio (INR) therapeutic range which requires high-quality anticoagulation management (HQACM). What constitutes HQACM of warfarin is poorly defined, as are the outcome measures of HQACM. The aim of this review is to identify and discuss the elements of HQACM of warfarin and to define, when possible, the appropriate measures to assess HQACM. This review specifically does not address the 'how to' of HQACM. For detailed information on managing the VKAs, the reader is referred to a number of excellent reviews.
Oral anticoagulation therapy with warfarin is the mainstay of prevention and treatment of thromboembolic disease. However, it remains one of the leading causes of harmful medication errors and medication-related adverse events. The beneficial outcomes of oral anticoagulation therapy are directly dependent upon the quality of dose and anticoagulation management, but the literature is not robust with regards to what constitutes such management. This review focuses on, and attempts to define, the parameters of high-quality anticoagulation management and identifies the appropriate outcome measures constituting high-quality management. Elements discussed include the most fundamental measure, time in therapeutic range, along with other parameters including therapy initiation, time to therapeutic range, dosing management when patients are not in therapeutic range, perioperative dosing management, patient education, and other important outcome measures. Healthcare providers who manage oral anticoagulation therapy should utilize these parameters as a measure of their performance in an effort to achieve high-quality anticoagulation management.
Oral anticoagulation therapy with the vitamin K antagonists (VKA), particularly warfarin, which is the most commonly used VKA, continues to increase worldwide due to the aging population and its efficacy in preventing stroke in patients with atrial fibrillation or recurrent thromboembolism in patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Despite improved awareness of warfarin's efficacy and safety, the management of warfarin remains complex due to its intricate pharmacokinetic and pharmacodynamic properties and narrow therapeutic range. It is among one of the top five medications associated with drug errors that cause harm and has been shown to be one of the most common causes of emergency room visits due to an adverse event. National healthcare regulatory agencies have recently targeted anticoagulants, including warfarin, as high-risk medications and are focused on ensuring the safe use of these agents. One such agency, the Joint Commission, has proposed new 2008 National Patient Safety Goals aimed at minimizing the risks associated with warfarin use and reducing adverse events.
The beneficial outcomes of oral anticoagulation therapy are directly dependent upon achieving and maintaining an optimal international normalized ratio (INR) therapeutic range which requires high-quality anticoagulation management (HQACM). What constitutes HQACM of warfarin is poorly defined, as are the outcome measures of HQACM. The aim of this review is to identify and discuss the elements of HQACM of warfarin and to define, when possible, the appropriate measures to assess HQACM. This review specifically does not address the 'how to' of HQACM. For detailed information on managing the VKAs, the reader is referred to a number of excellent reviews.