Episode 19: Early ED Discharge in Patients with low-risk VTE with DOACs with Jimmy Pruitt and Oscar Santalo

Background

1. In 2003 – 2014 inpatient hospital costs ranged from $3,018 to $5,040 per admission for a primary DVT diagnosis
2. Average DVT LOS can range from 4.9 – 7 days
3. Recurrent VTE that requires readmission could be up to 48% more costly than the initial event
4. Protocols for outpatient DVT management found a cost reduction of $2,470 per patient with enoxaparin
5. 36% of patients have expressed the inability to afford medications
6. In Burnett’s, et al study that discusses the DOAC patient selection criteria for DOAC use included:
   1. Adherence, patient follow up, confirmed ability to obtain DOAC
7. Falconieri’s and colleagues, et al found that none of 106 patients developed VTE recurrence on outpatient therapy
8. Did not experience clinically significant bleeding
9. Pharmacist-managed DVT program in the ED had a 91% initial clinic follow up
10. Rivaroxaban Starter Packs (RPAKs) given at discharge increases proper dose transition and overall adherence

Protocol & Pharmacy Workflow

Adult patients had to be stable and have a non-complicated lower DVT

• Workflow
  • The patient has confirmed DVT and meets inclusion criteria –> Provider enters order set and RPh verifies protocol–> Central pharmacy team labels then dispenses RPAK –> RN administers 1st dose out of pack and documents RPAK sent home with the patient –> Care navigation and TOC team follow up with the patient

1. Dispensed appropriate and compliant with Florida Limited Community Permit 64B16-28.810
   1. (e) A “multi-dose medicinal drug” as used in this rule means, but is not limited to, commercially available multi-dose packages such as inhalers, ocular products, insulin vials or pens, otic products, bulk antibiotic suspensions, topical agents, and methylprednisolone dose packets dispensed to inpatients, provided in containers that may exceed a three (3) day supply, and are intended to be continued by the patient on an outpatient basis but not to be re-filled by the hospital.

Summary

1. Early directed DVT with rivaroxaban starter packs have been proven to reduce admissions at 8 weeks
2. This research demonstrates how hospitals can be compliant with regulatory standards, pharmacy services, and serve the community by providing no additional out-of-pocket costs for the packs
3. Considering an estimated 900 admissions for uncomplicated DVT annually, our health system will have a projected cost savings of $2,678,901

Related FOAM Posts

EM@3AM: DVT

https://rebelem.com/tag/dvt/

Deep Venous Thrombosis (DVT)

References

Fernandez MM, Hogue S, Preblick R, Kwong WJ. Review of the cost of venous thromboembolism. Clinicoecon Outcomes Res. 2015 Aug 28;7:451-62. doi: 10.2147/CEOR.S85635. eCollection 2015.

Davis KA, Miyares MA, Price-Goodnow VS. Optimizing transition of care through the facilitation of a pharmacist-managed deep vein thrombosis treatment program. J Pharm Pract. 2013 Aug;26(4):438-41. doi: 10.1177/0897190012465953. Epub 2012 Nov 19.

Burnett AE, Mahan CE, Vazquez SR, et al. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis. 2016 Jan;41(1):206-32. doi: 10.1007/s11239-015-1310-7.

Falconieri L, Thomson L, Oettinger G, et al. Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program.  Hosp Pract (1995). 2014 Oct;42(4):16-45. doi: 10.3810/hp.2014.10.1140.

Beam DM, Kahler ZP, Kline JA. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med. 2015 Jul;22(7):788-95. doi: 10.1111/acem.12711. Epub 2015 Jun 25.

Castelli MR, Saint CA, Nuziale BT, et al. Effect of a Rivaroxaban Patient Assistance Kit (R-PAK) for Patients Discharged With Rivaroxaban: A Randomized Controlled Trial. Hosp Pharm. 2017 Jul;52(7):496-501. doi: 10.1177/0018578717721105. Epub 2017 Jul 25.

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