• G P Samsa, D B Matchar, L B Goldstein, A J Bonito, L J Lux, D M Witter, and J Bian.
• Center for Clinical Health Policy Research, Department of Medicine, Duke University Medical Center, Durham, NC 27705, USA. samsa001@mc.duke.edu
• Arch Intern Med. 2000 Apr 10;160(7):967-73.

BackgroundMost 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.ObjectiveAs 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.MethodsRetrospective 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.ResultsOnly 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.ConclusionsWe 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.

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