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Beth Israel Deaconess Medical Center, Boston, Massachusetts

Jennifer Mackey, PharmD ([email protected])
Diane Brockmeyer, MD ([email protected]).

A multidisciplinary approach to improve anticoagulation safety: improving patient re-engagement and adherence to their warfarin care plan.


Patients anticoagulated with Coumadin, who do not adhere to their care plan, are at significant risk for serious health complications. A common challenge for a Coumadin Clinic is how to standardize the outreach process to patients with chronic non-adherence.


Prevent Coumadin Clinic patient discharges. Re-engage patients in their anticoagulation care plan. Collaborate with physicians to optimize patient outreach efforts. Systematically identify and address potential adherence barriers.

Context & Intervention:

The BIDMC Coumadin Clinic is composed of nurses and a pharmacist who manage about 700 patients referred by physicians within a large academic primary care practice. A patient re-engagement protocol was created to standardize outreach efforts to non-adherent patients. Patients at least one week overdue for an INR test are identified through an electronic patient registry. Weekly reminder telephone calls, and periodic letters, are generated from the Clinic. Continued non-adherence prompts contact with physicians to encourage patient outreach and assessment of common potential adherence barriers (Table). Appointments involving the physician, Coumadin Clinic, and patient are recommended to formulate patient-specific plans to improve adherence. Patients are discharged from the Clinic after 12 consecutive weeks of non-adherence, but may be re-enrolled if three months of improved anticoagulation adherence are demonstrated with the physician.

Findings to date:

The Coumadin Clinic made 499 outreach attempts to 222 individual patients over six months. Recurrent non-adherence was noted in 78 of these patients, for a total of 300 patient non-adherence episodes. Overall staff adherence to the re-engagement protocol process was 94%. Physicians were contacted on 54 occasions regarding chronically non-adherent patients at least four weeks overdue for an INR. Subsequent telephone calls, letters, referrals, and/or scheduled clinic visits were documented in patients’ medical records as physician outreach efforts. The most common factors identified as preventing INR adherence were: patient ambivalence over anticoagulation need, perceived lack of vulnerability for clot development, transportation, significant life events, and mental health.

Outreach efforts also identified lack of BIDMC notification regarding patients who were admitted to outside institutions, expired, traveling, or transferring care. Of the remaining 291 non-adherence episodes, INRs were eventually drawn on 285 patients (98%) following multidisciplinary outreach. These patients were on average 13 days (range 3-83, mode 6) overdue for an INR. The majority of overdue INR results were within normal limits; 24% of results were subtherapeutic and 13% supratherapeutic. No adverse events were reported. Physicians discontinued anticoagulation in 4 patients given their risk-benefit profiles. Two patients were discharged from the Clinic after failing to respond to 12 weeks of re-engagement attempts; one patient was re-referred after demonstrating improved adherence.

Key lessons:

A standardized multidisciplinary process for addressing INR draw recommendation non-adherence is effective in re-engaging anticoagulated patients. Primary care physicians are willing to partner with the Coumadin Clinic to reach out to vulnerable patients. The majority of patients are up to two weeks overdue for blood tests, and receptive to outreach efforts. Successful anticoagulation requires ongoing patient education. Re-engagement processes require continued refining to decrease recurrent non-adherence episodes.


BIDMC Coumadin Clinic team members include: Patricia Glennon-Colby, RN; Lisa Jachowicz, LNP; Marie Mahony, RN, Colleen Monbleau, RN; and Carolyn Wheaton, RN

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