Clinical Outcomes of a Pharmacy-Led Blood Factor Stewardship Program

Abstract

To report the results of a pharmacist-directed blood factor stewardship program targeting off-label utilization designed to limit use to established organizational guidelines in high-risk populations. Prospective evaluation of recombinant factor VIIa and prothrombin complex concentrate orders beginning June 2013 through May 2014 and a matched retrospective cohort from June 2012 to May 2013. Matched cohorts were evaluated for 28-day mortality, change in international normalized ratio (INR), adverse events, concurrent blood product use, and cost savings. Forty-two orders for blood factor were ordered between June 2013 and May 2014, 70 orders in the year before (N = 112). Twenty eight–day mortality was not different between the cohorts: 53.9% versus 50% (P = 0.77). Blood factor use with underlying liver failure and active bleeding was strongly associated with 28-day mortality: odds ratio (95% confidence interval), 2.9 (1.5–7.14) and 2.91 (0.01–2.91), respectively. Blood products dispensed increased over the year with plasma products the most significant (1 vs. 4 P = 0.004). All other clinical outcomes were nonsignificant. An annual cost savings of $375,539 was achieved, primarily through a significant reduction in recombinant factor VIIa and avoidance in high-risk patients. Use of off-label blood factors can be controlled through a pharmacist-led stewardship program. Twenty eight–day mortality was not different between the 2 cohorts; however, identification of risk factors for death associated with blood factor use allows for restriction in high-risk populations, creates a discussion of futile care, and yields cost savings.

Collaborative Management Strategies for Drug Shortages in Neurocritical Care

“…During times of shortage, institutions may consider restricting PCC4 to patients requiring reversal of vitamin K antagonists for major bleeding or emergent surgery and using alternative agents for off-label indications (e.g., reversal of direct acting oral anticoagulants, major bleeding during cardiac surgery, and treatment of coagulopathy secondary to liver dysfunction). A prospective blood factor stewardship program has been shown to reduce inappropriate use of PCC4 [33,34].…”

Antithrombotic and hemostatic stewardship: evaluation of clinical outcomes and adverse events of recombinant factor VIIa (Novoseven®) utilization at a large academic medical center

“…15 In addition, Trueg et al conducted an evaluation of rFVIIa and PCC orders before and after implementation of a pharmacist-directed blood factor stewardship program. 19 Mortality at 28 days was similar between groups (53.9% versus 50%, p = 0.77); however, there was an annual cost savings of $375,539, primarily through a significant reduction in rFVIIa utilization. 19 Similar to these studies, we found a decrease in rFVIIa administered with the implementation of an off-label dosing guideline, leading to a $414,500 decrease in the annual costs of rFVIIa.…”

“…19 Mortality at 28 days was similar between groups (53.9% versus 50%, p = 0.77); however, there was an annual cost savings of $375,539, primarily through a significant reduction in rFVIIa utilization. 19 Similar to these studies, we found a decrease in rFVIIa administered with the implementation of an off-label dosing guideline, leading to a $414,500 decrease in the annual costs of rFVIIa. This may have been attributed to the recommendation for lower initial starting doses, the use of dose rounding, and purchasing multiple vial strengths to limit waste.…”

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

“…Emergency anticoagulation reversal involves using an appropriate reversal agent at an appropriate dose in response to either a life‐threatening bleed or for an emergency procedure. A retrospective cohort evaluated the impact of a pharmacist‐led blood factor stewardship program and found that total CA during 1 year was $375,539, amounting to $8941.40 per patient . A similar study found that a pharmacist working with a hematologist resulted in an annual savings of more than $4 million in blood factor stewardship .…”

“…A retrospective cohort evaluated the impact of a pharmacist-led blood factor stewardship program and found that total CA during 1 year was $375,539, amounting to $8941.40 per patient. 69 A similar study found that a pharmacist working with a hematologist resulted in an annual savings of more than $4 million in blood factor stewardship. 70 The actual cost savings for specific types of interventions were not provided.…”