ASHP Best Practices Award Mortar and Pestle

Award Information

Advancing into Unchartered Territory: Impact of an Innovative Factor Stewardship Program on Drug Expense, Patient Care, and a Pharmacist’s Role

Lindsey B. Poppe, PharmD, MS, BCPS; Sheh-Li Chen, PharmD, BCOP; Rowell Daniels, PharmD, MS; Nigel Key, MB, ChB, FRCP; Stephen F. Eckel, PharmD, MHA, BCPS, FAPhA, FASHP; Scott W. Savage, PharmD, MS


University of North Carolina Hospitals

Clotting factor concentrates (CFC) or blood factor products (e.g. recombinant factor VIIa, factors, VIII, IX, and factor VIII/von Willebrand’s) accounted for 11% or approximately $7.9 million of University of North Carolina Hospital’s (UNCH) drug expense budget for fiscal year (FY) 2010. Recognition by hospital administration of this large aggregate expense, as well as most hospitals in the nation at that time caused significant pressure to ensure optimal use of these products in a cost-effective manner.   Pharmacy leadership designated CFCs as a strategic area of interest with a goal to ensure that patients with high CFC utilization receive the same or better therapeutic outcome through optimized product use.   After a comprehensive literature review, proposed CFC Guidelines were created by pharmacists with experience in CFC management. A gap analysis of current practices compared to the proposed CFC guidelines identified opportunities for pharmacist intervention within patient management throughout the medication use process. Collaboration between pharmacy, hospital administration, nursing, and physician leadership proposed a detailed plan centered on the creation of a Pharmacist-driven Factor Stewardship Program with the mission “to treat all patients with the most efficacious, safest, and least costly CFC for the appropriate duration of time required to achieve adequate hemostasis.” 

Two phases were proposed in the implementation plan. Phase one was to select one formulary product for each class of CFC, implement the proposed CFC guidelines, and develop an institutional education plan. Phase two was to create a Factor Stewardship Program led by the Department of Pharmacy in collaboration with UNC’s Hemophilia Treatment Center. To our knowledge, this is the first pharmacy-led, multidisciplinary supported Factor Stewardship Program in the nation.

The Factor Stewardship Program, led by a benign hematology pharmacist, has been in place for over two years (July 2011-present). The consistent pharmacist oversight and coordination has led to significant cost savings and improved patient outcomes.  Through optimization of CFC product selection, dosing regimens, and infusion frequency, the number of CFC doses has reduced by 45%, despite a 22% increase in patient volume. Improved product selection resulted in optimized care for patients with hemophilia A with inhibitors.  For example, converting from rFVIIa to FEIBA had equal or more clinical efficacy and reduced readmissions due to bleeding episodes (e.g. three in FY12 to zero in FY13). This conversion also led to a cost savings of greater than $1.8 million for one patient during one single hospital admission. This reduction, along with other initiatives to enforce the CFC guidelines specifically in cardiothoracic surgery and neurosurgery, has demonstrated more than $4 million in cost savings annually.

UNC Hospital’s Factor Stewardship Program represents an innovative and unique approach to a challenging patient population. The improved patient care, including reduced readmissions, and cost savings initiatives since implementation of the program is a best practice that can be modeled in other institutions. This program created a new pharmacist practice model in an area that has been unchartered in our profession.

View a pdf of the poster from the Midyear Meeting (259 KB)