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A Transition in Care Initiative:  Implementation of a Pharmacy Directed Anticoagulation Program in the Orthopedic Population

Lynda Thomson, Pharm.D., CACP; Michael Palladino, Pharm.D., CACP; Cindy Wordell, Pharm.D., BCPS, FASHP; Brian Swift, Pharm.D., M.B.A.; Geno Merli, M.D.; Javad Parvizi, M.D.


Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

Venous thromboembolic disease (VTED) is estimated to affect 2 million Americans per year, with a resulting cost of care of 1.5 billion dollars per year. In the United States, VTED is the most common post-operative medical complication and third most common cause of post-operative death. Inpatient and outpatient pharmacy driven anticoagulation models are well documented and have consistently shown improved clinical and economic outcomes.  The initial purpose of our Pharmacy Managed Anticoagulation Program was twofold: to optimize the use of post-operative antithrombotic prophylaxis in an effort to improve clinical outcomes in the orthopedic population and to develop a model that insured a smooth transition of care for patients from the inpatient to outpatient setting. 

The Pharmacy Managed Anticoagulation Program consists of an interdisciplinary team of pharmacists, nurse practitioners, physician assistants, case managers, pharmacy residents, and surgeons. A dedicated pharmacy team manages each orthopedic patient’s post-operative antithrombotic therapy starting the day of surgery and up until 6 weeks or longer, depending on the indication for anticoagulation. Pharmacists are responsible for ordering medication and pertinent labs and adjusting anticoagulation medication accordingly. A comprehensive standardized assessment and education model was developed to insure that every patient receives medication education and discharge instructions prior to discharge. After discharge, the patient’s medication is managed by telephone or face-to-face visits.

The program began July 13, 2009 and managed 1,767 patients during its first year. Data was collected and analyzed for two representative periods: the pre-program period (January 1, 2009 - July 1, 2009) and the post-program period (July 13, 2009 - July 1, 2010).  Clinical outcomes were as follows:  the percentage of inpatient bleeding events decreased from 1.37% pre-program to 0.15% post-program.  Post-operative deep vein thrombosis was reduced from an incidence of 1.22% pre-program to 0.4% in the post-program period.  The incidence of post-operative pulmonary embolism was found to be 0.91% pre-program versus 0.8% post-program.  A formalized patient satisfaction survey using a telephone questionnaire consisting of a series of questions, with a scoring system scale of 1 to 5 (5 = “excellent” and 1 =“very poor”), was used to measure participants’ satisfaction with the program. The results revealed an overwhelmingly positive view of the program, with an overall average score of 4.7.

The Pharmacy Managed Anticoagulation Program is an innovative transition of care model that has improved clinical outcomes associated with anticoagulation prophylaxis in the post-operative orthopedic population.  The program has resulted in high patient satisfaction and has been enthusiastically accepted by the orthopedic team.  Incorporation of pharmacists into the interdisciplinary team is important to improve patient care and satisfaction and to facilitate the transition of care process.

View a pdf of the poster from the Midyear Meeting (589 KB).