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Organizational Characteristics of High- and Low-Performing Anticoagulation Clinics in the Veterans Health Administration

Authors

  • Adam J. Rose,

    Corresponding author
    1. Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
    2. United States Department of Veterans Affairs, Washington, DC
    • Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA
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  • Beth Ann Petrakis,

    1. Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA
    2. United States Department of Veterans Affairs, Washington, DC
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  • Patricia Callahan,

    1. United States Department of Veterans Affairs, Washington, DC
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  • Scott Mambourg,

    1. United States Department of Veterans Affairs, Washington, DC
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  • Dimple Patel,

    1. United States Department of Veterans Affairs, Washington, DC
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  • Elaine M. Hylek,

    1. Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA
    2. Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
    3. United States Department of Veterans Affairs, Washington, DC
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  • Barbara G. Bokhour

    1. Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA
    2. United States Department of Veterans Affairs, Washington, DC
    3. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA
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Address correspondence to Adam J. Rose, M.D., M.Sc., F.A.C.P., Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Road, Building 70, Bedford, MA 01730; e-mail: adamrose@bu.edu.

Abstract

Objective

Anticoagulation clinics (ACCs) can improve anticoagulation control and prevent adverse events. However, ACCs vary widely in their performance on anticoagulation control. Our objective was to compare the organization and management of top-performing with that of bottom-performing ACCs.

Data Sources/Study Setting

Three high outlier and three low outlier ACCs in the Veterans Health Administration (VA).

Study Design

Site visits with qualitative data collection and analysis.

Data Collection/Extraction Methods

We conducted semi-structured interviews with ACC staff regarding work flow, staffing, organization, and quality assurance efforts. We also observed ACC operations and collected documents, such as the clinic protocol. We used grounded thematic analysis to examine site-level factors associated with high and low outlier status.

Principal Findings

High outlier sites were characterized by (1) adequate (pharmacist) staffing and effective use of (nonpharmacist) support personnel; (2) innovation to standardize clinical practice around evidence-based guidelines; (3) the presence of a quality champion for the ACC; (4) higher staff qualifications; (5) a climate of ongoing group learning; and (6) internal efforts to measure performance. Although high outliers had all of these features, no low outlier had more than two of them.

Conclusions

The top-performing ACCs in the VA system shared six relatively recognizable characteristics. Efforts to improve performance should focus on these domains.

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