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Alexandra Papaioannou Courtney Kennedy Glenda Campbell Jacqueline Stroud Luqi Wang Lisa Dolovich

Team-based approach to warfarin management in long term care: A feasibility study of the MEDeINR electronic decision support system. Alexandra Papaioannou Courtney Kennedy Glenda Campbell Jacqueline Stroud Luqi Wang Lisa Dolovich Mark Crowther. BMC Geriatrics 2010, 10:38.

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Alexandra Papaioannou Courtney Kennedy Glenda Campbell Jacqueline Stroud Luqi Wang Lisa Dolovich

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  1. Team-based approach to warfarin management in long term care: A feasibility study of the MEDeINR electronic decision support system Alexandra Papaioannou Courtney Kennedy Glenda Campbell Jacqueline Stroud Luqi Wang Lisa Dolovich Mark Crowther BMC Geriatrics 2010, 10:38

  2. Papaioannou et al. BMC Geriatrics 2010, 10:38 Background Previous studies in long-term care (LTC) have shown warfarin management to be suboptimal with preventable adverse events occurring as a result of poor International Normalized Ratio (INR) control.

  3. What were the objectives? • Apply evidence to improve warfarin care in LTC • settings • Develop an electronic decision support system to facilitate prescribing and monitoring (MEDeINR) • Provide training and support to promote uptake of the tools and overcome implementation barriers Papaioannou et al. BMC Geriatrics 2010, 10:38

  4. What methods were used? • Feasibility study • Pre-post design • All residents on warfarin in 6 LTC homes (n=128) • excluded 1 resident with prosthetic valve • INR Data Collection • Baseline International Normalized Ratio (INR) • 3 month retrospective chart audit • 3 month INR data collected after implementation of MEDeINR system Papaioannou et al. BMC Geriatrics 2010, 10:38 4

  5. How did MEDeINR work in this study? • MEDeINR – an electronic decision support system: • Staff person logs on to MEDeINR and enters certain information including INR value obtained from lab • MEDeINR recommends an overall weekly dose; a specific daily dose is also provided • Nursing staff: • Prints MEDeINR recommendation • Contacts physician (via phone or fax) • Faxes MEDeINR recommendation forms to pharmacy • Places the original on resident's chart • Physicians could request access to the on-line tool if they wished to check MEDeINR recommendations themselves Papaioannou et al. BMC Geriatrics 2010, 10:38 5

  6. MEDeINR • A web-based calculator • Used by nurses and physicians • Assists in accurately adjusting warfarin doses to help maintain INR in therapeutic range • Available on-line, 24 hours a day BMC Geriatrics 2010, 10:38 6

  7. Outcomes • Primary Outcomes: • Time in Therapeutic Range (TTR) • Time in sub- or supra-therapeutic ranges • Secondary Outcomes: • Number of monthly INR tests per resident • Survey of focus group feedback from LTC teams • Analysis: • Within patient comparison / paired analysis • Included all INR values for every resident on warfarin; exception - residents who had fewer than 2 INR values in either pre or post phase 7 Papaioannou et al. BMC Geriatrics 2010, 10:38

  8. Results • Baseline TTRs were higher in this cohort than in previous studies • Overall, TTRs increased during the MEDeINR phase (65 to 69%) • significantly increased for one home (62% to 71%, p <0.05). • Percentage of time in supra-therapeutic range decreased (14% to 11%, p = 0.08) Papaioannou et al. BMC Geriatrics 2010, 10:38 8

  9. Results, cont’d • Little change for the sub-therapeutic range (21% to 20%, p = 0.66). • Overall, the average number of INR tests/30 days decreased from 4.2 to 3.1 (p < 0.0001) per resident after implementation of MEDeINR. • Feedback from LTC clinicians and staff : MEDeINR program decreased workload, improved confidence in management and decisions, and generally easy to use. Papaioannou et al. BMC Geriatrics 2010, 10:38 9

  10. Conclusion • MEDeINR Program represented a useful tool to: • Promote optimal TTR • Decrease INR venipunctures • Streamline processes • Increase nurse and physician confidence around warfarin management • Note: LTC homes in this study had good TTRs prior to the intervention, likely due to involvement in previous quality improvement initiatives; homes with poorer warfarin control may possibly see greater gains with MEDeINR. • MEDeINRis a practical, usable clinical information system that can be incorporated into the LTC environment. 10 Papaioannou et al. BMC Geriatrics 2010, 10:38

  11. Acknowledgments • This work was funded by: • Canadian Institute of Health Research – Knowledge Translation grant • (FRN: KTS-73426) • Medical Pharmacies Group Ltd. Papaioannou et al. BMC Geriatrics 2010, 10:38 11

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