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BACKGROUND/RATIONALE:
Atrial fibrillation (AF) is a major cause of preventable stroke; anticoagulation with warfarin decreases stroke risk, but warfarin's narrow therapeutic window necessitates careful monitoring of anticoagulation blood levels (INR). Clinicians may have concerns that patients with mental health conditions (MHC) will not be able to remain safely within this therapeutic window. However, it is not known how often patients with MHC receive anticoagulation therapy, nor how they actually fare on it. We will use existing data sources to examine processes and outcomes of stroke prevention care in AF for patients with MHC (compared to those without MHC).
OBJECTIVE(S):
Our primary objectives are: To characterize eligibility for anticoagulation in patients with and without MHC; To determine whether processes of care (receipt of anticoagulation, Time in Therapeutic Range of INR) and outcomes (strokes, bleeds, death) differ for patients with and without MHC; To explore whether associations vary by MHC type; To examine whether failure to receive patient-centered care mediates the association between MHC and processes of care; and To quantitate the near-term cost to VA of excess anticoagulation-related events in patients with MHC.
METHODS:
VA patients with AF will be identified from national FY01-FY02 VA and Medicare administrative records; processes of care will be examined in FY03 records (VA Pharmacy Benefits Management files to identify use of warfarin, Decision Support System Lab Results files to ascertain INR values), and outcomes of care in FY03-FY05 records (VA's Integrated Stroke Outcome Database to identify strokes, and VA and Medicare administrative files to identify bleeds and deaths). Receipt of patient-centered care will be identified using measures derived from the Office of Quality and Performance's FY03 Survey of Healthcare Experiences of Patients. Patients with MHC (and with specific types of MHC) will be compared to those without MHC on process and outcomes of care.
FINDINGS/RESULTS:
As we report in an abstract accepted for poster presentation at the Society of General Internal Medicine Regional Meeting, our analyses from the chart review component of this study of patients with atrial fibrillation treated at one VA facility have demonstrated that patients with mental illness are less likely than those without mental illness to be prescribed warfarin, even in the absence of standard contraindications. When treated with warfarin, patients with mental illness were more likely to have INR lab values outside of the therapeutic range. These preliminary findings support the importance of our ongoing work with the large national administrative databases.
IMPACT:
This study is well aligned with the objectives of VA's Stroke QUERI, Mental Health QUERI, and Substance Use Disorders QUERI, and will make important contributions to VA's stroke prevention quality improvement efforts. If we find that many patients with MHC are receiving anticoagulation, our work will identify subgroups of the mentally ill who spend disproportionate amounts of time outside of the therapeutic range, and examine how often they experience adverse events (strokes, bleeds, deaths). This will serve to clarify whether there are subgroups of patients with MHC who cannot use warfarin safely, and who might be appropriate candidates for targeted use of expensive emerging treatments like direct thrombin inhibitors. It will also clarify whether there are subgroups of patients with MHC who can use warfarin safely; such information would be important reassurance for clinicians who may hesitate to anticoagulate any patient with MHC. By examining the contribution of failure to receive patient centered care to observed disparities, we will identify promising directions for future interventions research targeted at patients with MHC and/or their providers. Finally, while VA is internationally recognized for its research on mental health care for patients with MHC, researchers have only recently begun to examine the medical care needs of patients with MHC. Stroke prevention in AF is an ideal prototype for such work. To the extent that we identify opportunities for quality improvement in AF care, it will raise the possibility that quality improvement opportunities abound for a whole spectrum of medical conditions when associated with mental health comorbidity.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases, Health Services and Systems, Mental Illness
DRE:
Communication and Decision Making, Resource Use and Cost
Keywords:
Patient outcomes, Stroke, VA/non-VA comparisons
MeSH Terms:
none
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