Quality statement 4: Anticoagulation control

Quality statement

Adults with atrial fibrillation taking a vitamin K antagonist who have poor anticoagulation control have their anticoagulation reassessed.

Rationale

Improving poor anticoagulation control by reassessing the international normalised ratio (INR) at each visit can ensure that a person's risks of stroke and of having a major bleed are as low as possible.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that adults with atrial fibrillation taking a vitamin K antagonist have their anticoagulation reassessed if their anticoagulation control is poor.

Data source: Local data collection.

Process

a) Proportion of adults with atrial fibrillation taking a vitamin K antagonist who have their time in therapeutic range (TTR) recorded at each visit for INR assessment.

Numerator – the number in the denominator who have their TTR recorded at each visit for INR assessment.

Denominator – the number of adults with atrial fibrillation taking a vitamin K antagonist.

Data source: Local data collection.

b) Proportion of adults with poor anticoagulation control who have it reassessed.

Numerator – the number in the denominator who have their anticoagulation reassessed.

Denominator – the number of adults with poor anticoagulation control.

Data source: Local data collection.

Outcome

a) Rates of thromboembolic complications.

Data source: Local data collection.

b) Patient experience.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) have systems in place with written clinical protocols for reassessing anticoagulation in adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.

Healthcare professionals reassess anticoagulation and record the results for adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.

Commissioners (clinical commissioning groups) commission secondary care services that have written clinical protocols for reassessing anticoagulation in adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.

What the quality statement means for patients, service users and carers

Adults with atrial fibrillation who are taking a type of anticoagulant called a vitamin K antagonist (such as warfarin) have their anticoagulation treatment reassessed if regular tests show that it isn't working well.

Source guidance

Atrial fibrillation (2014) NICE guideline CG180, recommendations 1.5.11 (key priority for implementation), 1.5.12, 1.5.13 and 1.5.14 (key priority for implementation)

Definitions of terms used in this quality statement

Poor anticoagulation control

Poor anticoagulation control can be shown by any of the following:

  • 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months

  • 2 INR values less than 1.5 within the past 6 months

  • TTR less than 65%.

The NICE guideline on atrial fibrillation recommends that TTR is measured at each visit and at least annually, and that healthcare professionals should:

  • use a validated method of measurement such as the Rosendaal method for computer‑assisted dosing or proportion of tests in range for manual dosing

  • exclude measurements taken during the first 6 weeks of treatment

  • calculate TTR over a maintenance period of at least 6 months.

[Atrial fibrillation (NICE guideline CG180), recommendations 1.5.11, 1.5.12 and 1.5.18]

Reassessing anticoagulation

The NICE guideline on atrial fibrillation recommends that the following factors should be taken into account and addressed if they are contributing to poor anticoagulation control:

  • cognitive function

  • adherence to prescribed therapy

  • illness

  • interacting drug therapy

  • lifestyle factors including diet and alcohol consumption.

If poor anticoagulation control cannot be improved as a result of this reassessment, the risks and benefits of alternative stroke prevention strategies should be evaluated and discussed with the person.

[Adapted from Atrial fibrillation (NICE guideline CG180), recommendations 1.5.13 and 1.5.14]