ANTITHROMBOTIC STEWARDSHIP: A

MULTIDISCIPLINARY APPROACH TO IMPROVE

ANTITHROMBOTIC THERAPY

David Reardon, PharmD BCPS

September 18th, 2015

Tri-State Health-System Pharmacy Summit

Disclosures

David Reardon has received consulting fees from Boehringer Ingelheim

Pharmacist Objectives

Compare and contrast anticoagulation management services and anticoagulation stewardship programs

Identify areas of target for anticoagulation stewardship programs

Describe interdisciplinary approaches to improving anticoagulation utilization and decreasing costs

Technician Objectives

Identify potential technician roles in an anticoagulation stewardship

Describe medication reconciliation approaches to improve anticoagulant use

Anticoagulation

Less than 65 years 66 - 74 years 75+ years0

2

4

6

8

10

12

14

16

18

20

0.650000000000004

5.6

10.2

Anticoagulant Usage by Age in 2007

Per

cent

age

Beauregard KM et al. Agency for Healthcare Research and Quality. October 2009

A Need for Change

War

farin

Insu

lins

Ora

l Ant

iplat

elets

Ora

l Ant

idiab

etics

Opio

ids05

101520253035 33.3

13.9 13.310.7

4.8

Emergency Hospitalizations in the Elderly

Per

cent

age

Budnitz DS, et al. NEJM. 2011;365:2002-12

Anticoagulation Management Services (AMS)

Provide a specialized service in one areaWarfarin management

Improved therapeutic efficacy and decrease in adverse eventsDecrease in total treatment costsCost avoidance

Biscup-Horn PJ, et al. J Thromb Thrombolysis. 2008,25:129Padron M, et al. J Pharm Pract. Epub ahead of print

Antithrombotic Stewardships Programs (ASP) Inpatient-focused program Incorporate principles of AMS Focus on transitions of care

Patient education and follow up Design, implement, and enforce institutional

protocols Determine areas of improvement

Medication use evaluations (MUE)Formulary reviewHigh risk patient populationsExpose gaps in therapy management

Padron M, et al. J Pharm Pract. Epub ahead of printReardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

Identifying Targets Institution specific

High cost medications (IV direct thrombin inhibitors, anti-platelets, NOACs)

MUEs○ Determine appropriateness of utilization and

off-label use○ Medication frequently associated with adverse

events

Attainable resultsRealistic short and long-term goals

Reardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

Potential Targets Management of heparin-induced thrombocytopenia

(HIT)Minimize costs of expensive IV therapies such as direct

thrombin inhibitors (DTIs) Initiate non-heparin anticoagulation quicklyTransition to long-term therapy Improve vitamin K administration

Dosing of anticoagulation in patients with mechanical circulatory support devices (i.e. ventricular assist device, total artificial heart)High risk patient populationRequire highly skilled management

Oversight of anticoagulation in patients receiving extracorporeal membrane oxygenation (ECMO)

Reardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

Getting the Key Players Together

ASP

Pharmacy

Hematology

Hospital Leadership

?

Blood Bank

Lab

Hospital Leadership Quality Assessment and Process

ImprovementEnsure The Joint Commission National Patient

Safety Goals metImprove patient care and decrease re-admissions

Business plans and fundingApprove more FTE support

Provide top-down support Enforcement of clinical initiativesWide-spread communication to those affected by

change

Pharmacy Specialized training in antithrombotic

managementWarfarin management clinicsInpatient heparin management services

Budgetary motivation Structure for management

Pharmacy clinical servicesMedication reconciliation

○ Medication reconciliation techniciansPharmacy and Therapeutics CommitteeCollaborative Drug Therapy Management

Physician Champion

Hematology/Cardiology/Internal Medicine

Physical championsServe as medical director of ASPWrite and review protocols and guidelines

Have “skin in the game”Proper diagnosis and therapy utilization

reduces unnecessary workloadImproved patient follow up and outcomes

Lab

Proper utilization of resourcesDecrease in time performing unnecessary

testsAbility to fast-track resultsProtocol and guideline development

Blood Bank

Reversal strategies and agentsProtocol and guideline developmentBlood productsClotting factors

Tactics for Success Formulary Restriction

Authorization for useLimited indications for useOrder entry restriction

Audit with Intervention and FeedbackProspective vs. retrospective

EducationGrand rounds, orientation, patient care rounds

Clinical pathways and guidelinesProper diagnosis, treatment, and discharge

planning

Drew. J Manag Care Pharm. 2009;15:S18-23

Pharmacist Activities Dosing and reviewing antithrombotics in designated

patient populationsDrug-drug interactionsHepatic/renal dysfunction

Daily progress notes Stewardship rounds Patient monitoring and laboratory follow up Protocol and guideline development Committee participation ASP progress updates to hospital leadership Research and publication Student and resident precepting

Management of HIT: Target Identified Fiscal year 2013 DTI costs: $1,087,647

directly associated with HITImproper diagnosis

○ Dogmatic approach to diagnosis○ Not “believing” laboratory data

Prolonged transition○ Unsure of long-term plan○ Perceived barriers of fondaparinux therapy

Reardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

Management of HIT: Action Plan Created Update institutional guideline for HIT Management

Easy to use 4Ts scoring sheetAppendix with rationale behind guideline

Clinical surveillance of anti-heparin PF4 antibody and serotonin release assays

Follow up after DTI initiationPharmacist-written note in medical record

○ Reviewed with Hematology attending○ Recommendations for therapy○ Ability to stop therapy

Targeted educational activitiesSenior physicians and their teams

Reardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

DTI Use in HIT

782 patients evaluated

592 patients included

152 patients excluded

259 post-ASP patients333 pre-ASP patients

Bivalirudin Cumulative Use in HIT Patients by Month

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep0

200000

400000

600000

800000

1000000

1200000

FY13FY14

Reardon, et al. J Thromb Thrombolysiss. 2015;40:379-82

Exp

endi

ture

in M

illi

ons

of D

olla

rs

Months

Changes in HIT Treatment Costs

 Variable All Patients

N=592

Pre-ASP

n=333

Post-ASP

n=259

Cost of fondaparinux, dollars $28,772.78 $4,159.92 $24,612.86

Cost of DTI, dollars $423,142.70 $266,689.40 $156,453.30

Total drug cost of DTI and fondaparinux, dollars $451,915.48 $270,849.32 $181,066.16

Cost data: $784.56/vial of bivalirudin, $198.57/vial of argatroban, $346.66/syringe of fondaparinux.

Decrease in duration of DTI therapy in patients with suspected or diagnosed HIT pre- vs. post-ASP (4.07 vs.

2.86 days, p=0.01)

Barriers to Implementation and Success

Time devotion and funding Disrupting the “status quo” Protocol and guideline adherence Pharmacist vs. physician-driven service Lack of specific “antithrombotic-trained”

pharmacists

Drew. J Manag Care Pharm. 2009;15:S18-23

Questions?