Reduction In Epistaxis And Emergency Department Visits In Patients Taking Warfarin After Implementation Of An Education Program

Background: Anticoagulated patients are often seen unnecessarily in the emergency department (ED) for epistaxis, leading to increased healthcare costs. Patients are often unaware of preventative and management techniques for handling epistaxis in the home.Methods: In 2016, the Michigan Anticoagulation Quality Improvement Initiative (MAQI(2)), a Blue Cross Blue Shield of Michigan-sponsored consortium of 6 anticoagulation clinics in Michigan, implemented an epistaxismanagement educational program for warfarin-treated patients with the goal of reducing unnecessary ED visits. A pre-implementation cohort (2014-2015) consisted of patients who did not receive epistaxis-related educational materials. A post-implementation cohort (2017-2018) received epistaxis educational materials covering home treatment and prevention strategies. Patient characteristics and outcomes (rates of epistaxis and epistaxis ED visits) were compared using Chi-square, Poisson regression, and t-tests.Results: Of the 4473 patients included, 2634 (58.9%) initiated warfarin in the pre-implementation phase and 1839 (41.1%) initiated warfarin in the post-implementation phase. The post-implementation cohort had a lower overall epistaxis rate (13.4 vs 10.4 per 100 patient-year, pre- vs. post-implementation; p = 0.029), a lower epistaxis-related ED visit rate (5.6 vs. 3.1 per 100 patient-year; p = 0.003), and a lower proportion of nosebleeds that led to an ED visit (42% vs. 30%; p = 0.032). After controlling for antiplatelet use, renal disease, and time in therapeutic range, both cohorts were equally likely to have nosebleeds (RR 0.77, 95% CI: 0.58-1.02); however, the post-implementation cohort was less likely to visit the ED for epistaxis (RR 0.52, 95% CI: 0.32-0.84).Conclusion: An epistaxis education program was associated with a reduction in epistaxis-related ED visits among warfarin-treated patients.