The Clinical Thrombosis Center and Clinical Thrombologist: A New US Health Systems Paradigm for the Management of Venous Thromboembolic Disease

The U.S. Thrombosis and Hemostasis Centers pilot sites program

Venous thromboembolism (VTE) is a common disorder associated with significant morbidity and mortality. Despite important advances in understanding the etiology of VTE, delivery of care to patients with thrombosis and thrombophilia is frequently incomplete and highly variable. A comprehensive model of health care has been used successfully to treat and prevent complications for people with hemophilia and other chronic disorders. The effectiveness of an integrated healthcare model for patients with all coagulation disorders has yet to be evaluated. The Division of Hereditary Blood Disorders of the Centers for Disease Control and Prevention (CDC) is collaborating with eight Thrombosis and Hemostasis Centers (pilot sites) to provide health-related services and conduct research directed toward the reduction or prevention of complications of thrombosis and thrombophilia. The initial objectives of the collaboration are to (1) determine the efficacy of integrated multidisciplinary care and prevention services for people with hemostatic disorders, (2) assess unmet needs for service delivery and identify outreach strategies to improve access to care, (3) develop effective messages aimed at disease management and prevention, and (4) foster the development of training programs to enhance provider skills for the delivery of patient care. To address these objectives, the investigators and CDC have developed and implemented a web-based patient registry to follow prospectively service allocation and patient outcomes. Funding for the program began in October 2001. All eight funded centers are affiliated with U.S. medical schools. Principal investigators at the centers are hematologists (five adult, two pediatric) or cardiologists. Faculty in obstetrics-gynecology, surgery, and multiple other specialties are integral to the model of care at the centers. Other critical components at the centers are clinical laboratory services, training programs, research networks, and education and outreach programs. From August 2003 to March 2006, over 2,600 patients were enrolled in the registry, accounting for a total of more than 5,000 visits to the centers. Immediate goals of the data collection at the centers are to characterize patients receiving care at centers and document the state of health services provided. Long-term goals are to evaluate prospectively clinical outcomes for patients receiving multidisciplinary care and prevention services at centers. The network of data collection across centers will facilitate future collaborative clinical and epidemiologic investigations and enhance collective expertise in hemostasis and coagulation disorders.

Pharmacy-managed anticoagulation: Assessment of in-hospital efficacy and evaluation of financial impact and community acceptance

BACKGROUND

The dangers of thrombosis are well known and yet current therapy presents a paradox; effective methods of pharmacological anticoagulation are available, but underemployed. The risks associated with the use of anticoagulants, especially warfarin, and the requirement of meticulous dosing with subsequent vigilant monitoring provides some explanation for this discrepancy. Efforts have been made to address this incongruity and increase anticoagulation treatment while mitigating complications; these include the development of dosing nomograms, patient self-monitoring of anticoagulation status, and increased pharmacist participation in anticoagulation management. Although the latter option has proven effective in outpatient clinics, its in-hospital application has received less attention. Therefore, our primary goal was to review the published literature to evaluate the efficacy of in-hospital, pharmacy-managed anticoagulation. In addition, our secondary goals were to assess the potential financial benefit and community acceptance of such pharmacist management.

METHODS

Potentially relevant studies were identified by searching PubMed; however, because some pharmacy journals are not included in this database, we also used internet search engines to locate articles. We subsequently employed the Science Citation Index to find additional papers that had referenced articles identified by our initial searches.

RESULTS

Several pilot studies, focusing primarily on adherence to warfarin dosing guidelines, found general equivalence between pharmacist and physician management and specifically illustrated the potential benefit gained simply through adherence to protocols. Nevertheless, these studies frequently lacked appropriate statistical analysis and examined small, and often heterogeneous, patient groups. Larger comparative studies also possessed some of the same flaws; however, taken together the equivalence and, in some cases improvement, in patient outcomes (e.g., greater control of International Normalized Ratios and decreased length of hospital stay) that they demonstrated suggest the value of increased pharmacist participation in anticoagulation therapy. Studies using heparin-based anticoagulation reported similar positive findings and hence support the warfarin results. Both published studies examining financial implications of in-hospital pharmacy management indicated potential for considerable savings. Finally, although we identified no in-hospital studies of community acceptance, positive survey results indicted that the majority of physicians and patients accepted pharmacy-managed outpatient anticoagulation.

CONCLUSIONS

The reported outcomes of pharmacy-managed in-hospital anticoagulation therapy appear at least equal, and sometimes superior, to those obtained through standard care; however, the lack of large well-designed trials prevents drawing definitive conclusions. Nevertheless, the continued and likely increased future need for anticoagulation in general and warfarin therapy in particular suggests that increased pharmacist involvement could enhance the quality of patient care.

Transitioning from Traditional to Novel Anticoagulants: The Impact of Oral Direct Thrombin Inhibitors on Anticoagulation Management

Limitations of traditional anticoagulants have led to the need for structured services to provide anticoagulation monitoring. Anticoagulation management services have historically filled this role. Novel antithrombotic agents currently in development have the potential to improve on the limitations of vitamin K antagonists and injectable forms of heparin and to change the field of anticoagulation management. Of the emerging agents, oral direct thrombin inhibitors present the most promise and have a more practical clinical profile. The introduction of the oral direct thrombin inhibitors may present both an opportunity and a threat to anticoagulation management services and anticoagulation service providers. Traditional anticoagulation monitoring services will have to retool for the future if they are to remain relevant in the new era of novel antithrombotic.agents.