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Initiative to ‘avoid heparin’ reduces heparin-induced thrombocytopenia, costs
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An “avoid-heparin initiative” resulted in a substantial reduction in the burden of both suspected and diagnosed heparin-induced thrombocytopenia as well as associated costs, according to a study conducted over 10 years at Sunnybrook Health Sciences Center in Toronto.
Heparin-induced thrombocytopenia is a major complication that occurs in about 5% of patients who are exposed to unfractionated heparin. An initiative was introduced at Sunnybrook in 2006 to replace unfractionated heparin with low–molecular-weight heparin (LMWH).
William Geerts, MD
William Geerts, MD, a thrombosis specialist at Sunnybrook and professor of medicine at University of Toronto, and colleagues conducted this quality improvement study to determine the impact of an “avoid-heparin intervention” on the incidence of heparin-induced thrombocytopenia and its costs over the span of 10 years.
“The only method to prevent heparin-induced thrombocytopenia was to avoid nonessential patient exposures to heparin, one of the most common drugs used in hospitals,” Geerts told HemOnc Today. “Although our initial objective was to try to reduce heparin-induced thrombocytopenia in cardiovascular surgery, we soon realized that we could not focus on one patient group only — there had to be comprehensive, institution-wide changes.”
The initiative included the systematic replacement of unfractionated heparin with LMWH in prophylactic and therapeutic doses. Unfractionated heparin was still used in hemodialysis, during cardiovascular surgery and for some patients with acute coronary syndrome.
Additionally, heparinized saline was removed from all arterial and central venous lines and replaced with saline flushes; order sets were modified to exclude unfractionated heparin; and unfractionated heparin also was removed from most nursing units.
So as not to influence practice and to try to make this a ‘natural history’ study, most care providers were unaware of these changes or that the changes were being studied.
From 2003 to 2012, there were 1,118 cases of suspected heparin-induced thrombocytopenia. These patients underwent enzyme-linked immunosorbent assay testing for PF4-heparain antibodies, and 16% had a positive assay. Among those patients, 51% were adjudicated positive for heparin-induced thrombocytopenia.
The investigators split patients into two groups — 424 patients who were treated pre-intervention (from 2003-2005) and 576 patients treated after the intervention (2007-2012). Researchers excluded the year 2006 as that was the transition year for the implementation of the initiative.
The annual incidence of suspected cases of heparin-induced thrombocytopenia decreased 41.7% from 85.5 per 10,000 hospital admissions in the pre-intervention phase to 49 per 10,000 hospital admissions in the after intervention phase (P < .001).
The annual incidence of positive assays decreased 62.9%, from 16.5 per 10,000 admissions to 6.1 per 10,000 admissions (P < .001).
Adjudicated heparin-induced thrombocytopenia decreased 79% annually, from 10.7 to 2.2 per 10,000 admissions (P < .001). Researchers also observed a 90.7% decrease in the annual incidence of heparin-induced thrombocytopenia with thrombosis (4.6 to 0.4 per 10,000 admissions; P < .001).
Overall, the mean number of cases of suspected heparin-induced thrombocytopenia decreased from 141.3 per year in the pre-intervention period to 96 per year in the “avoid-heparin” period, while the annual number of cases decreased from 17.7 to 4.3.
This change conferred a decrease in the average estimated costs of heparin-induced thrombocytopenia care annually from $322,321 in the pre-intervention period to $55,383 in the “avoid-heparin” period (measured in 2007 Canadian dollars).
The researchers acknowledged some limitations, specifically that the study was conducted at a single institution that may have differing heparin-induced thrombocytopenia-related practices, thereby affecting the generalizability of the results. Also, since all cases were adjudicated retrospectively, a potential bias in case definition exists.
“We recommend that all hospitals carefully consider the findings of this study and determine if they should also implement avoid-heparin strategies to improve patient safety and reduce costs,” Geerts said. – by Anthony SanFilippo
McGowan KE, et al. Blood. 2016;doi:10.1182/blood-2015-07-660001.
Disclosure: Geerts reports consultant/advisory roles and other financial relationships with Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Janssen, Leo Pharma, Pfizer and Sanofi. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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