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Implications of an inpatient warfarin dosing nomogram on safety outcomes post-discharge

Journal of Thrombosis and Thrombolysis volume 43, pages 454–462 (2017)Cite this article

Abstract

Many hospitals have implemented warfarin dosing nomograms to improve patient safety. To our knowledge, no study has assessed the impact inpatient warfarin initiation has in both medical and surgical patients, on safety outcomes post discharge. To evaluate the impact of a suggested institutional nomogram for the initiation of warfarin, the primary endpoint was the incidence of bleeding throughout follow up. Secondary endpoints included the composite of INR changes ≥0.5/day and INR >4. Patients were followed for a period of 2 weeks post-discharge. The composite endpoint was evaluated for an effect on reaching therapeutic INR, time to reach therapeutic INR, and bleeding events throughout follow up. A single center retrospective study comparing the safety of adherence vs. non-adherence to a warfarin nomogram. A total of 206 patients were included, 73 patients in the nomogram adherence vs. 133 in the nonadherence arm. There was no difference in the proportion of patients who bled throughout the follow up period, adherence 9.6% vs. nonadherence to the nomogram 13.5%, p = 0.407. There was however a statistical difference in the mean total number of bleeding events, 0.096 (7/73) in the adherence vs. 0.158 (21/133) in the non-adherence arm, p = 0.022. There was also no difference in the composite endpoint, 19.2% in the adherence vs. 28.6% in the non-adherence arm p = 0.180. A positive correlation between the inpatient composite and risk of bleeding throughout follow up was noted. The findings of this study support adherence to the nomogram as opposed to non-adherence.

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Authors and Affiliations

  1. UMass Memorial Medical Center, Worcester, MA, USA

    Jennifer L. Donovan, Robert Klugman, Joel Gore & Maichi T. Tran

  2. Massachusetts College of Pharmacy and Health Sciences, Worcester, MA, USA

    Jennifer L. Donovan & Maichi T. Tran

  3. University of Massachusetts Medical School, Worcester, MA, USA

    Jennifer L. Donovan, Robert Klugman, Joel Gore & Maichi T. Tran

  4. School of Pharmacy, Lebanese American University, Po Box 36, Byblos, Lebanon

    Nibal Chamoun & Pascale Salameh

  5. Baystate Medical Center, Springfield, MA, USA

    C. Gabriela Macías

Authors
  1. Nibal Chamoun
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  2. C. Gabriela Macías
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  3. Jennifer L. Donovan
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  4. Robert Klugman
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  5. Joel Gore
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  6. Pascale Salameh
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  7. Maichi T. Tran
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Correspondence to Nibal Chamoun.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Appendix: Warfarin Order Form and Nomogram

Appendix: Warfarin Order Form and Nomogram

figure a
figure b

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Chamoun, N., Macías, C.G., Donovan, J.L. et al. Implications of an inpatient warfarin dosing nomogram on safety outcomes post-discharge. J Thromb Thrombolysis 43, 454–462 (2017). https://doi.org/10.1007/s11239-016-1462-0

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  • DOI: https://doi.org/10.1007/s11239-016-1462-0

Keywords

  • Warfarin
  • Anticoagulation
  • Nomograms
  • Inpatient
  • Safety