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VTE Prophylaxis
Venous thromboembolism (VTE) prophylaxis was a recurring theme throughout the presentations relating to anticoagulation medications at the midyear clinical meeting of the American Society of Health-System Pharmacists (ASHP) on December 5-9 in Orlando, Florida. A large number of studies, in both teaching and community-based hospitals, took as their starting point the recommendations from the American College of Chest Physicians (ACCP) guidelines.

Using the sixth ACCP guidelines for prevention of VTE [1] to define appropriate prophylaxis, 2 such studies reported audits of prophylaxis use in the wards of their hospitals. Price et al. [2] reported preliminary results of a study of VTE prophylaxis in 40 medical patients in a large teaching hospital. In this study, 30% of patients were receiving VTE prophylaxis, 20% of patients had a contraindication to prophylaxis, 30% were receiving treatment doses of anticoagulation, and 20% did not have sufficient risk factors to warrant VTE prophylaxis. Furthermore, the most common risk factors observed in this population were age > 40 years, prolonged immobility, and heart failure.

A second study by Kristufek and Manzey [3] assessed the hospital charts of 34 medical or surgical patients for deep-vein thrombosis (DVT) risk in a 250-bed community hospital. Patients were stratified into low-, medium-, high-, or very-high-risk categories according to guidelines. Overall, 26% of patients received appropriate prophylaxis, including 100% of patients in the low-risk category and 66% of patients in the medium-risk category. Indeed, only 6% of the high-risk and 0% of the very-high-risk patients received appropriate prophylaxis.

It was widely acknowledged at the meeting that pharmacists could play a major role in the improvement of medical strategy. The above studies are a case in point, with both studies leading to the development of a “prophylaxis order form” to be used within the hospital by the physicians. Simple interventions such as these by pharmacists are likely to have a large impact on improving prophylaxis patterns at a low cost in terms of time.

Oral Anticoagulation
Another hot topic at the ASHP midyear clinical meeting in 2004 was the issues surrounding maintaining a therapeutic international normalized ratio (INR) in patients receiving warfarin.

A study by Winter et al. [4] undertook a retrospective chart study of the characteristics and outcomes of oral anticoagulation in elderly patients (> 75 years old). In a population of 103 elderly patients attending an outpatient anticoagulation clinic, approximately one half of the INRs were within the therapeutic range, one third of the INRs were subtherapeutic, and one sixth of the INRs were supratherapeutic. Interestingly, this distribution was similar to that of the control patients, indicating that although the dosing regimens might vary, elderly patients are just as likely as younger patients to be within the therapeutic range. No major adverse events were reported in this population. Specifically, no major bleeds were reported, although a number of minor bleeds were observed.

If, however, a patient does report with a supratherapeutic INR, the ACCP guidelines include recommendations for the management of such patients. DeGennaro et al. [5] retrospectively studied 41 patients who were admitted with an INR > 4.0 and compared the length of stay of those patients managed according to guidelines with that of patients who were not. Compliance with ACCP guidelines was observed in 49% of patients, and these patients spent, on average, approximately 3 days less in hospital than those patients not managed according to guidelines.

Huang et al. [6] investigated further the importance of maintaining a therapeutic INR in a cost-based analysis of the impact of an anticoagulation pharmacy service. Of the patients who were hospitalized with a major hemorrhage, 60% of the control patients compared with 30% of the study patients had a supratherapeutic INR. Furthermore, the average cost of hospitalization (in 2000) for the control group was US $26,233 compared with an average of just US $13,625 (in 2003) in the intervention group.
 
Cost-saving Strategies With Low-molecular-weight Heparins
Alongside the patient-safety initiatives as described in the other reports, a major focus for the pharmacist is to develop initiatives that will result in cost savings at no detriment to the healthcare provided. To this end, 2 interesting studies of strategies for cost savings with the low-molecular-weight heparin enoxaparin were presented at the midyear meeting.

A study investigating the cost of treating heparin-induced thrombocytopenia (HIT) was presented by Kang et al. [7] In a period of 1 year, an estimated 508 patients with suspected HIT were seen in the authors’ institution following treatment with unfractionated heparin. A retrospective chart analysis of 38 patients with HIT produced a calculated total cost of treating these patients of US $272,635. Extrapolating this cost to the full cohort of suspected HIT patients gave the investigators an estimated cost of treatment of US $3,644,701 per year. By switching from unfractionated heparin to enoxaparin, the authors postulated that a saving of over US $2,000,000 per year was possible, despite the acquisition costs of enoxaparin.

In another study, Li et al. [8] reported on cost savings that were possible with current enoxaparin use. Having observed inappropriate dosing of enoxaparin in their institution, they initiated an intensive pharmacist education program that included case studies, meeting highlights, and assessment. The impact of this education was seen quickly in terms of a 50% increase in the average assessment score following education compared with the pre-education average score. Moreover, increases in the appropriate dosing of enoxaparin have been noted and have led to large cost savings while concurrently improving safe practice for the patient.

References

1. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119:132S-175S.
2. Price VS, Sanchez M, Phillips A. Evaluation of the use of venous thromboembolism (VTE) prophylaxis in medical patients of a large teaching hospital [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P250R.
3. Kristufek LR, Manzey LL. Assessment of deep vein thrombosis prophylaxis in general medical-surgical patients [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P35E.
4. Winter ME, Chou C, Hill S, Cavanan G, Kayser SR. Anticoagulation management in the very elderly [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P33E.
5. DeGennaro L, Comer JB. Evaluation of hospitalized patients with warfarin induced international normalized ratios greater than 4.0 [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P241R.
6. Huang VC, Miyahara RK, Fiuzat M. Outcome analysis and cost-justification of anticoagulation therapy monitoring by clinical pharmacists [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P133E.
7. Kang SK, Wordell CJ, Senholzi C, Chambers L. Cost of enoxaparin for prevention and/or treatment of thromboembolic events vs. the cost of treating heparin-induced thrombocytopenia (HIT): a cost-benefit analysis [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract MCS-18.
8. Li B, Fahey T, Newberg D. Staff development: making a difference to ensure appropriate enoxaparin dosing [abstract]. Presented at ASHP 39th Midyear Clinical Meeting and Exhibits, December 5-9, 2004, Orlando, FL. Available at: http://ashp.omnibooksonline.com/2004/. Abstract P103D.

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At discharge, current guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) recommend that patients who have suffered an acute myocardial infarction (MI) be started on 4 primary medications: aspirin (an antiplatelet drug), a beta-blocker, an angiotensin-converting enzyme (ACE) inhibitor, and a 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG co-A) reductase inhibitor (a statin). One of the 2004 American Society of Health-System Pharmacists (ASHP) Best Practices in Health-Systems Pharmacy awards was for a program designed to encourage the prevention of secondary MI through administration of medications prescribed under the current ACC/AHA guidelines.

Initially, Kessels and colleagues at Barnes-Jewish Hospital, St Louis, Missouri, looked at baseline prescribing rates for each of the 4 classes of drugs in patients discharged following treatment for acute MI: aspirin was the highest (88%), while ACE inhibitors and beta-blockers were in the 60% to 70% range.  Statins were prescribed in 80% of patients. To test a methodology designed to increase compliance, patients were randomized to an intervention arm in which they were followed by a pharmacist to make sure they were on all 4 medications at discharge; if not, an intervention was made by the pharmacist who alerted the prescribing physician. The control arm received normal care without pharmacy intervention. At the end of the study, discharge prescription rates—the primary endpoint—were significantly higher for 3 out of the 4 recommended drugs in the group followed by the pharmacist. Only aspirin use, for which prescription rates were relatively high at baseline, did not significantly increase.

The poster presented at ASHP meeting described a broader implementation phase of the study. During the initial study period, only 1 or 2 pharmacists followed all of the patients admitted with acute MI. The goal of the operational phase was to involve pharmacists in each area throughout the hospital who might have acute MI patients admitted to their floor. Using computer technology, information was disseminated to make pharmacists aware of acute MI patients and also to track discharge therapy. Pharmacists were alerted to patients who were not receiving the 4 recommended medications and, unless there was a specific contraindication, they followed up with the prescribing physician. Using this system, the pharmacy department was able to maintain the same compliance rates hospital-wide that had been achieved during the initial study.

Award recipients: Anthony Kessels, PharmD; Thomas Bailey, MD; Laura Noirot, BS; William C. Dunagan, MD; Erin Rachmiel, PharmD; Rina Shah, PharmD; Barnes-Jewish Hospital, St Louis, Missouri.

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