We often talk about how patient compliance and failure to keep office visits impact negatively on the health of our patients. Yet when one looks at interactions with the healthcare system, it is clear that most such patients indeed have interacted with someone in the healthcare system and that many opportunities to intervene are missed. We often see patients who never get their preventive health measures (eg. immunizations) but were seen in an emergency department or other non-PCP setting at a time in which that preventive measure could have been delivered.
Now a new study (Meeker 2011) of patient visits to emergency departments shows an even bigger opportunity to intervene is being overlooked. They looked at patients presenting to the ED who were discharged from the ED without admission and found that 2% of all patients were taking warfarin for one reason or another. Over 70% of those patients had an INR drawn, almost half of which showed the patient was not in the therapeutic range. The ED providers addressed the undesired state of anticoagulation only 21% of the time. They were more likely to intervene when INR was in the supratherapeutic range but only 41% of those with an INR below the therapeutic range had either anticoagulant-related discharge instructions (34%) or an intervention (9%). Many of those patients with non-therapeutic INR’s were taking other medications potentially interacting with warfarin.
So this is another good example of how our fragmented healthcare system fails to provide optimal overall medical care. This is a prime example of how various players in the healthcare system have limited ability to communicate with each other and especially limited ability to agree on responsibility for managing important clinical problems.
Meeker E, Dennehy CE, Weber EJ, Kayser SR. Emergency Department Management of Patients on Warfarin Therapy. Ann Emerg Med 2011; 58: 192-199