Computerized clinical decision support improves warfarin management and decreases recurrent venous thromboembolism

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"Background: An explicit approach to warfarin dose adjustment using computerized clinical decision support (CDS) improves warfarin management. We report metrics of quality for warfarin management before and after implementation of CDS in a large health care system. Methods: A total of 2591 chronically anticoagulated patients were eligible for inclusion. We compared interpatient time in therapeutic range (TTR) and international normalized ratio (INR) variability before and after implementation of CDS. We report outcomes of major bleeding, thrombosis, and health care utilization. Results: Implementation of CDS significantly improved TTR (from 63.99% to 65.13%; P ¼ .04) and reduced out-of-range INRs (from 42.39% to 39.97%; P < .001). Venous thromboembolism (relative risk [RR] 0.41; P < .001) emergency department utilization (RR 0.62; P < .001), and hospitalization (RR 0.62; P < .001) were reduced after CDS implementation. Major hemorrhage was more frequent after CDS implementation (RR 1.42; P ¼ .01). Conclusion: The CDS warfarin management was associated with improved TTR and decreased INR variability in a large cohort of chronically anticoagulated patients. Clinically relevant outcomes were broadly improved, although more bleeding events were observed."[1]


The purpose of this research study was to monitor if the implementation of a CDS tool that helps manage warfarin would improve the length of time the drug was in therapeutic range (termed TTR). In addition, they studied if the international normalized ratio (INR) variability would improve as well.


This was a retrospective study that required patients to have had 10 INRs in the year prior to the implementation of the CDS tool and a minimum of 10 more after implementation. Every time an INR lab was run or when a patient failed to appear for a repeat INR lab draw, an alert was triggered within the EMR. If a dose adjustment was needed or a follow-up INR was needed, the CDS algorithms would activate predetermined protocols.


For the TTR, the results showed a slightly greater than 1% increase after implementation of the CDS tool (pre-CDS period 63.99% and post-CDS period 65.13%). For the INR variability, the average number of daily INRs out-of-range prior to implementation was 105.07 and post implementation the value decreased to 86.71.


The CDS tool was able to show improvement with regards to both measurements. In addition, the authors also found that there was a relative risk reduction in venous thromboembolisms. However, there was a concerning rise in bleeding events after implementation of the CDS tool.


Many times, patients are lost to follow up or not accounted for when they don't show up for necessary blood draws. Because of the triggers this tool has when patients fail to appear for repeat INR lab draws, I think this really helps improve the results of this study.


  1. Woller, S. C., Stevens, S. M., Towner, S., Olson, J., Christensen, P., Hamilton, S., … Elliott, C. G. (2015). Computerized Clinical Decision Support Improves Warfarin Management and Decreases Recurrent Venous Thromboembolism. Clinical and Applied Thrombosis/Hemostasis, 21(3), 197–203.