Implementation of a Pharmacist Directed Anemia Management Service in the Inpatient Setting
Coleen N. Moriarity-Suggs, Pharm.D., Nicole Y. Gann, Pharm.D., Rheta A. Sandoval, Pharm.D., James R. McNulty, Pharm.D.
Kaweah Delta Medical Center, Visalia, California
Erythropoiesis-stimulating agents (ESAs), epoetin alfa and darbepoetin alfa, are some of the most expensive medications used in the hospital setting. Additionally, inappropriate use of these agents has been shown to cause serious adverse cardiovascular events. A Medication Use Evaluation (MUE) conducted in 2006 revealed potential for improvement in the prescribing and monitoring of epoetin alfa (EPO) for inpatients at our institution. This led to the development of the Anemia Management Pharmacy Service (AMPS) to promote the safe and cost-effective use of ESAs in the inpatient setting.
AMPS is a pharmacist-managed, consult-driven service that uses a protocol based on current national guidelines and literature recommendations for the medical treatment and monitoring of anemia. Pharmacist assessment includes a review of the patient chart for pertinent medical information, documentation on a monitoring form, and independent ordering of laboratory studies. For chronic dialysis patients, a current anemia medication history is obtained from the outpatient dialysis clinic. Medication therapy, including EPO, iron, folic acid, and Vitamin B-12 supplements, may be ordered by the pharmacist when indicated by the protocol. Patient hemoglobin response, laboratory studies, and clinical condition are evaluated during treatment to guide medication therapy changes in order to achieve and maintain therapeutic goals. For patients prescribed EPO without an AMPS consult, the pharmacist evaluates the appropriateness of therapy and makes recommendations for changes to the prescriber if indicated.
Prospective EPO MUEs were conducted in 2007 (844 patients) and 2008 (895 patients) to track the progress and impact of the AMPS. Analysis included indication, dosing and monitoring of EPO, determination and treatment of other causes of anemia, adverse events, and patient hemoglobin response. Pharmacist management of EPO therapy was compared to physician management. The MUE data revealed that following implementation of the AMPS fewer patients were prescribed EPO for non-FDA-approved indications (10% reduction), EPO was prescribed in dose and frequency more consistent with current guidelines (42% overall decrease in units/kg/week EPO), more patients were evaluated for iron deficiency (44% increase), and a greater average change in hemoglobin was observed compared to baseline (0.4 g/dL increase) In contrast with physician management, pharmacist managed patients were prescribed lower average doses of EPO, had more dose reductions in response to elevated hemoglobin, and experienced a lower frequency of serious adverse events. The overall cost savings (direct cost savings plus cost avoidance) attributed to AMPS during the first two years was greater than $380,000. That AMPS has gained support from medical staff is evidenced by a two-fold increase in AMPS consults after the first year. AMPS continues to provide an important link in the continuity of care in the chronic hemodialysis patient population by ensuring optimal management of anemia medications during hospitalization.
The implementation of an innovative clinical pharmacy service to improve the utilization of anemia-related medications demonstrates that the expansion of pharmacist services into the arena of the treatment of anemia can positively impact patient outcomes in a way that reshapes and redefines the practice of pharmacy.
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