1. GHS Outpatient Enoxaparin Program
Rondell Jaggers, PharmD
Grady Health System
Atlanta, Georgia

3. Grady Health System
Core Mission: Care for the medically underserved

4. Pharmacy & Drug Information
11 Outpatient Prescription Pharmacies
Inpatient Pharmacy + four satellites
Clinical Pharmacy Services
Pharmacy Administrative & Support Services
Pharmacy residency program
PGY1
PGY2 (Internal medicine, infectious diseases, critical care, oncology, and emergency medicine)

5. Objectives
Describe GHS Pharmacy Services outpatient enoxaparin program
Explain the process for initial assessment and follow up in clinics
Discuss staffing model
Describe the program’s impact on hospital admissions and length of stay (LOS)

6. Outpatient Enoxaparin Program
Initiated in 2006
Developed and managed by clinical pharmacy staff and pharmacy residents
Program goals
Safe and efficient process to bridge patients to warfarin and facilitate hospital discharge (or avoid admissions)

7. Process Consultation Financial criteria met? Financial counselingNo
Financial criteria met?
Yes
Yes
Financial counseling
Contraindications? No
Continue Heparin
Consult Service
Assessment
Inclusion/exclusion criteria
Financial status
Education
Discharge
Oupatient follow-up
Referral to Coumadin Clinic
Institutional practices
Physician preference
Suggestion: in last row of flow diagram, the middle box, include name of clinic, “Outpatient f/u in Lovenox clinic, therapeutic?”
Enroll in Enoxaparin Program
Reschedule follow-up visit No
Outpatient Follow-up, therapeutic?
Yes
Referral to Coumadin Clinic

8. Inpatient Assessment

9. Inclusion Criteria Deep vein thrombosis
Established warfarin patient requiring temporary discontinuation of warfarin
Subtherapeutic INR
Atrial fibrillation
Coagulopathies

10. Exclusion Criteria Not willing to self-inject
Active or high risk of bleeding
Obesity (>150 kg)
Unstable PE
Liver disease
HD dependent
History of HIT or hemorrhagic stroke
Unable to return for follow-up visit
Noncompliance
Financial constraints

11. Exclusion from Outpatient Program
Pregnancy
Coagulopathies
Prophylaxis
Orthopedics
Surgery
Hematology/Oncology
Infectious Diseases Ponce Clinic

12. Education Indication Mechanism of action Dosing Administration
Adverse effects
Drug-drug and drug-food interactions
Storage of syringes

13. Discharge Dosing Approval of patient self-injection technique
Pharmacist co-signature
Progress note
Outpatient follow-up appointment

14. Outpatient Follow-up Assessment Reschedule or referral Compliance
Monitoring of INR
Worsening symptoms
New onset VTE or PE
Adverse effects
Medications
Diet
Reschedule or referral

15. Number of Patients Evaluated Monthly 1/1/2008 – 7/31/2008

16. Indications for Therapy
*stroke, protein C deficiency, anti-phospholipid syndrome, and cancer prophylaxis

17. Outpatient Enoxaprin Program
Patients screened
N = 109
Patients not receiving
enoxaparin
n = 15
Patients receiving
enoxaparin
n = 94
Patients requiring
PharmD follow-up
n = 83
Patients not requiring
PharmD follow-up
n = 11

18. Follow-up Total number of patients with clinic visits 63
Average number of follow-up visits/patient 2
Total number lost to follow-up 51
Average number of days from discharge to therapeutic INR 9
Average cost of enoxaparin therapy*
(based on 90-mg dose)
$810 / patient
Total cost of enoxaparin therapy†
$51,030
* Average cost per day = (180 mg/day) x (1 ml/100 mg) x ($0.50/mg) x 9 days = $810/patient
† Total cost of enoxaparin therapy = $810/patient x 63 patients = $51,030

19. Outpatient Enoxaparin Program
Hospital Admissions and Length of Stay
Not included in Program
(n = 26)
Included in Program
(n = 83)
Average LOS (days) 13 5
Average LOS after date of screening (days) 2
0.5
Patients who were admitted (%) 93 81

20. Outpatient Enoxaparin Program
Hospital Readmission Rates
Not included in Program
(n = 26)
Included in Program
(n = 83)
Patients readmitted after screening date (%) 35 28
Average time in days to readmission 23 57

21. Conclusions
389 hospital days were spared by initiating enoxaparin therapy
Cost savings during the 6-month period were ~$389,000
Estimated savings for one year is $778,000

22. Number of Patients Evaluated Monthly 1/1/2008 – 7/31/2008 and 1/1/2009 – 4/30/2009

23. Outpatient Enoxaparin Program
Promotes safe anticoagulation management practices
Results in cost avoidance
Decrease LOS
Avoid admissions
Access to patient assistance program
Facilitates training of pharmacy residents