title: Assessing the impact of a heparin-induced thrombocytopenia protocol on patient management, outcomes and cost.
abstract: Establishing the diagnosis of heparin induced thrombocytopenia (HIT) is challenging as laboratory tests for HIT vary in specificity and availability. As HIT suspicion far exceeds confirmation of diagnosis, overtreatment is an emerging concern. This pilot study evaluated the impact of a HIT Recognition and Management Protocol on direct thrombin inhibitor (DTI) prescribing, outcomes, and cost. The primary endpoint was DTI cessation within 12 hours of receipt of negative HIT serology. An observational cohort study using a pre-post design was performed. Sixty-one patients were in the pre-period (before implementation) and 46 in the post-period (after implementation). DTI therapy was discontinued within 12 hours of negative serology in 19.4% of pre-period patients compared to 40% of post-period patients, p=.058. DTI therapy was discontinued within 24 hours of receipt of a negative PF4/heparin ELISA more often in the post-period; 7/23 (30.4%) pre-period patients versus 16/26 (61.5%) post-period patients, p <0.05. Protocol implementation resulted in a significant improvement in timely initiation of DTI therapy (within 12 hours of HIT antibody testing) in those with a moderate to high suspicion of HIT; 8/31 (25.8%) of pre-period patients versus 24/31 (77.4%) of post-period patients, p <0.0001. Thrombotic events occurred in significantly more patients in the pre-period as compared to the post-period; 21/61 (34.4%) versus 6/46 (13%), respectively, p = 0.01. Major bleeding was reduced by 6.6 % after protocol implementation. The projected annual cost savings from decreased inappropriate DTI use was over $450,000. Protocol implementation had a positive impact on DTI prescribing, outcomes and cost.
authors.affiliation: Department of Pharmaceutical Services, Beaumont Hospital, Detroit, Michigan 48073, USA. msmythe@beaumont.edu
authors.forename: Maureen A
authors.initials: MA
authors.lastname: Smythe
authors.forename: John M
authors.initials: JM
authors.lastname: Koerber
authors.forename: Trupti P
authors.initials: TP
authors.lastname: Mehta
authors.forename: Lisa L
authors.initials: LL
authors.lastname: Forsyth
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Conger
authors.forename: Lindsey R
authors.initials: LR
authors.lastname: Corbets
authors.forename: Joan C
authors.initials: JC
authors.lastname: Mattson
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D000991:Antithrombins / Q000008:administration & dosage / Q000191:economics; D002985:Clinical Protocols; D015331:Cohort Studies; D023381:Endpoint Determination; D005260:Female; D017048:Health Care Costs; D006493:Heparin / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012189:Retrospective Studies; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000175:diagnosis* / Q000191:economics / Q000628:therapy; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D006493:Heparin