Survey uncovers barriers to therapy compliance
Misperceptions lead to underutilization
Stroke is the leading cause of death in the Unites States, costing more than $23 billion annually in acute and chronic care expenditures. Yet, of the 20% of strokes caused by atrial fibrillation (AF), warfarin anticoagulation in carefully chosen patients can reduce the risk of stroke by up to 68%, says Martha J. Radford, MD, FACC, clinical coordinator for the Connecticut Peer Review Organization (CPRO) in Middletown.
So when CPRO’s statewide record review of 770,000 Medicare hospitalizations in 1994 showed only 37% of patients with indications and no contraindication were on warfarin at hospital admission, and 50% were on warfarin at hospital discharge, Charles B. Seelig, MD, MS, acted on the audit immediately.
"The information showed us what we weren’t doing. What we wanted to know was why we weren’t doing it," says Seelig, director of medical education at Greenwich Hospital.
Greenwich’s CQI team created a successful stroke prevention program that is serving as a model at the state as well as the national level.
The team’s clinical guidelines, care maps, and physician reminder system has improved and standardized the hospital’s AF care. For example, a chart audit of all appropriate AF patients discharged in August through September last year showed a 61% use of anticoagulation therapy, compared with 42% during the same period of the previous year.
One of the keys to Greenwich’s 43% improvement was that in addition to continuing the chart abstraction work begun by CPRO, the CQI team also developed an anonymous questionnaire to measure physicians’ attitudes, knowledge, and perceived barriers toward anticoagulation.
"We discovered their knowledge base was excellent," Seelig says. "What was happening was an issue of perception. They believed they were anticoagulating more frequently than they actually were."
The results of the questionnaire showed physicians reported they used warfarin for 80% of the appropriate patients, when the chart abstraction data showed only 40%. It also compared the attitudes of physicians who were high users with those who used the therapy less frequently. "We were surprised to find there was no difference," Seelig says.
However the team did find a large difference between risk taking behavior on the part of the physicians who used less anticoagulation therapy less frequently. "To a greater degree [than the physicians who used the therapy more often], they felt that risk of the drug was not outweighed by benefits," explains Seelig. "We felt this was the crux of the issue: That some physicians take longer in accepting risky interventions than others." (See chart of risk factors for bleeding, p. 122.)
He developed the three-page survey by modifying one published in the Archives of Internal Medicine, adds Seelig who chaired the group. Other members included several physicians, two cardiologists, a neurologist, general internists, nurses, representatives from telemetry and intensive care, pharmacists, and a nurse educator.
"It was a unique intervention that linked the data we had collected to our questions about the underutilization," says Radford, who is also an associate professor of medicine at the University of Connecticut in Storrs. "It also heightened the awareness of the practicing community."
Examine the whole issue
After compiling the results from the physicians’ survey, the team decided that to affect the larger issue of AF patient management practices, it would have to consider the big picture.
"We designed a care map that looked at the whole process of atrial fibrillation, rather than anti-thrombotic therapy alone," Seelig says.
The team also created a risk assessment sheet that helps physicians determine whether or not the drug will be used. "We knew from the survey results that they needed a mechanism to determine risk," he says.
The sheet serves as a catalyst, reminding and encouraging physicians to make a decision as to whether or not to use anticoagulates.
Next, they educated physicians and nurses on the new approach. "We used both formal and informal means," Seelig says. "We discussed it during grand rounds with the physicians, in informal conferences with the residences, as well as an inservice for nurses on all floors where patients with atrial-fibrillation are likely to be admitted."
"It’s important in this type of CQI initiative that physicians do the presentations for other physicians because they can present it in a way that is not threatening," says Gail Doria, MPA, RN, director of quality management.
Radford agrees. "Anticoagulating for stroke prevention is a physician decision, so the physician community must be involved with it," she says.
For CQI professionals, that means incorporating this collaboration into the design of the project from the beginning. "It is a good way to introduce sometimes reluctant physicians to CQI, particularly if you can help with logistical things such as data gathering," Radford adds.
Rather than spend time developing handouts for the physician and patient education program, the team used materials from DuPont Merck in Wilmington, DE. "We knew this company has excellent materials, so we saw no need to reinvent the wheel," Seelig says.
The team has also recently completed a follow-up physician survey to determine how perceptions are changing. "We want to find out what is and isn’t working," Seelig says. For example, he questions if the transition to a computer order system will make using the reminder sheet cumbersome.
CPRO is also examining successful approaches to changing practice patterns among the 23 hospitals across the state as it compiles the latest results from its chart abstraction. Radford is preparing an article, which she hopes to publish in a peer reviewed journal this fall.
[For more information, contact Martha Radford, Connecticut Peer Review Organization, 100 Roscommon Drive, Middletown, CT 06457. Telephone: (860) 632-6310. Or Charles Seelig and Gail Doria, Greenwich Hospital, 5 Perryridge Road, Greenwich, CT 06830.]
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