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Results of a Review of Medical Records From 2 Communities

Gregory P. Samsa, PhD; David B. Matchar, MD; Larry B. Goldstein, MD; Arthur J. Bonito, PhD; Linda J. Lux, MPA; David M. Witter, MA; John Bian, MS

Arch Intern Med. 2000;160:967-973.

Background  Most treatment of patients at risk for stroke is provided in the ambulatory setting. Although many studies have addressed the proportion of eligible patients with atrial fibrillation (AF) receiving warfarin sodium, few have addressed the quality of their anticoagulation management.

Objective  As a comprehensive assessment of quality, we analyzed the proportion of eligible patients receiving warfarin, the proportion of time their international normalized ratios (INRs) were within the target range, and, when an out-of-target range INR value occurred, the time until the next INR measurement was made.

Methods  Retrospective review of the medical records of 660 patients with AF managed by general internists and family practitioners in Rochester, NY, and the Research Triangle area of North Carolina.

Results  Only 34.7% of eligible patients with AF received warfarin. The INR values were out of the target range approximately half the time, and the response to these values was not always timely. For all the measures considered, both Rochester practices with access to an anticoagulation service had higher (albeit not ideal) quality of warfarin management than the remaining practices.

Conclusions  We found significant deficiencies in the practice of warfarin management and suggestive evidence that anticoagulation services can partially ameliorate these deficiencies. More research is needed to describe the quality of anticoagulation management in typical practice and how this management can be improved.

From the Center for Clinical Health Policy Research (Drs Samsa, Matchar, and Goldstein and Mr Bian), the Departments of Medicine (Drs Samsa, Matchar, and Goldstein) and Community and Family Medicine (Dr Samsa), and the Center for Cerebrovascular Disease (Dr Goldstein), Duke University Medical Center, and the Department of Medicine, Department of Veterans Affairs Medical Center (Drs Matchar and Goldstein), Durham, NC; Research Triangle Institute, Research Triangle Park, NC (Dr Bonito and Ms Lux); and the Association of American Medical Colleges, Washington, DC (Mr Witter).

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