david reardon, pharmd bcps september 18 th, 2015 tri-state health-system pharmacy summit
TRANSCRIPT
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ANTITHROMBOTIC STEWARDSHIP: A
MULTIDISCIPLINARY APPROACH TO IMPROVE
ANTITHROMBOTIC THERAPY
David Reardon, PharmD BCPS
September 18th, 2015
Tri-State Health-System Pharmacy Summit
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Disclosures
David Reardon has received consulting fees from Boehringer Ingelheim
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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
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Technician Objectives
Identify potential technician roles in an anticoagulation stewardship
Describe medication reconciliation approaches to improve anticoagulant use
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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
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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
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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
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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
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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
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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
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Getting the Key Players Together
ASP
Pharmacy
Hematology
Hospital Leadership
?
Blood Bank
Lab
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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
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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
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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
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Lab
Proper utilization of resourcesDecrease in time performing unnecessary
testsAbility to fast-track resultsProtocol and guideline development
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Blood Bank
Reversal strategies and agentsProtocol and guideline developmentBlood productsClotting factors
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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
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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
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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
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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
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DTI Use in HIT
782 patients evaluated
592 patients included
152 patients excluded
259 post-ASP patients333 pre-ASP patients
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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
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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)
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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
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Questions?