More blood, sweat and tears: a qualitative analysis of warfarin management after discharge from hospital

Aim: Warfarin management remains a major therapeutic challenge, especially in the immediate post-discharge period. This qualitative study aimed firstly to identify the benefits and deficiencies of existing post-discharge warfarin management processes; and secondly to investigate the barriers to, and facilitators of, the implementation of a new, best practice post-discharge warfarin service currently being developed by the project team. Methods: Purposive, criterion-based sampling was utilised within Tasmania, New South Wales and the Australian Capital Territory to recruit patients recently discharged from hospital on warfarin and a range of healthcare providers involved in their care. The latter included general practitioners, haematologists, pharmacists and nurses, and representatives from their professional bodies. Between August and October 2008, 47 in-depth, semi-structured telephone interviews were conducted using standard discussion guides. Data were thematically analysed using a phenomenological framework. Results: Respondents identified the existence of 'ideal' discharge procedures for patients on warfarin, but current poor compliance to these processes. Desirable features of a post-discharge service included effective communication at the continuum of care, with timely and complete transfer of discharge information, and facilitation of early community followup. The potential benefits of more patient-friendly warfarin education material, improved opportunities for reinforcement of warfarin education, a home-delivered service and a home medicines review were also recognised. There was general support for the proposed post-discharge service model, although concerns were raised regarding issues of remuneration and the sustainability of the service. Conclusion: Deficiencies in the current post -discharge processes for patients on warfarin were acknowledged as placing them at risk of medication misadventure. A new post-discharge service has the potential to address many of these problems, although this analysis highlighted some potential barriers to its implementation which will be further addressed in the next phase of the project.