SIX YEARS EXPERIENCE USING AN ANTICOAGULATION BENCHMARKING MODEL

SIX YEARS EXPERIENCE USING AN ANTICOAGULATION BENCHMARKING MODEL

Dr Mike Galvin, Consultant Haematologist, Pinderfields and Pontefract Hospitals NHS Trust, Wakefield

From the Proceedings of the Dawn AC User Group 1999

Analysis of 6 years of data

Dr Galvin opened his presentation with a brief look back at the pre-Dawn era in Wakefield and stressed the importance and pivotal role of the Phlebotomist in the new arrangements as the only person who has direct patient contact at each INR check and hence the conduit for updated and accurate/vital information. The situation 'before' and 'after' are summarised by two cartoons by Nick Georgiou, a member of staff (see end of proceeding).

Dr Galvin presented a benchmarking analysis of 6 years of data since Dawn AC was introduced in 1993. Dr Galvin pointed out that this analysis had been carried out recently and stressed that in his view the talk would have been very different if the benchmarking had been available from the outset. In this case the table below of "percentage time in range" instead of being almost identical year by year over this six years would, he believed, have shown a progressive improvement, particularly in achieving a higher percentage of time in range earlier in the therapy life cycle (see graph below) focusing the mind as the benchmarking does on areas where there appears to be room for improvement.

Range 2-3

	1994	1995	1996	1997	1998	1999
% Time in Range	68.7	70.3	67.4	68.5	70.2	69.4
% Time Above Range	17.7	12.8	14.3	12.3	11.1	11.6
% Time Below Range	13.7	16.9	18.3	19.2	18.7	19
% Dose Manual Intervention	3.8	4.9	12.6	13.2	14.1	14.6
% Interval Manual Intervention	3.8	4.2	13	13.7	15.9	16.2

Range 3-4.5

	1994	1995	1996	1997	1998	1999
% Time in Range	60.3	58.4	62.8	60.4	65.1	68.7
% Time Above Range	6.7	7.6	10.1	9.7	8.7	9.4
% Time Below Range	33	34	27.1	29.9	26.3	21.9
% Dose Manual Intervention	33	34	27.1	29.9	26.3	21.9
% Interval Manual Intervention	2.7	6	16.5	15.7	21.8	24.7

This graph compares our hospital with other sites in terms of time in range. We are above average for all sites.

The benchmarking comparison with other sites for manual intervention (i.e. overriding the computer) for dose and interval setting (see graph below) shows a dramatically lower level of intervention by the site with the highest proportion of time in range which suggests the possibility that our well meaning attempts to "improve" on the computer are, in large measure, misplaced and counter productive. This possibility deserves detailed scrutiny in computer benchmarking exercises. Note also the mean test interval comparison.

It is the hope now that future benchmarking will indeed start to show the beginnings of an improvement in outcome which will be built on year by year.

He closed by emphasising the gap that now exists in our ability to relate the efficacy of control of anticoagulation to outcome in terms of bleeding and thromboembolic events. He made the rather provocative suggestion that with further training on how to record events, it could be possible for the Phlebotomist, with the Biomedical Scientists and others, to help to fill this gap so that we can audit not only how well we maintain our patients within the therapeutic range of anticoagulation but how effective this is in preventing thromboembolism whilst avoiding bleeding episodes.

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