Josée Martineau

Pharmacoeconomic Analysis of Fondaparinux Versus Enoxaparin for the Prevention of Thromboembolic Events in Orthopedic Surgery Patients

IntroductionFondaparinux is a novel synthetic antithrombotic that has been evaluated for the prevention of venous thromboembolism (VTE). In four large trials in patients who underwent major hip or knee surgery, fondaparinux was found to have a good safety profile and be more effective than enoxaparin. To generate Canadian pharmacoeconomic data for fondaparinux, an internationally developed cohort deterministic model was used to estimate the costs and consequences of prophylaxis with fondaparinux compared with enoxaparin in the Canadian orthopedic surgical setting.Design and settingA health economic advisory group was assembled to guide the pharmacoeconomic evaluation. Efficacy and safety data for fondaparinux relative to enoxaparin were abstracted from a meta-analysis of four randomized trials. Canadian cost data to populate the model were obtained from a resource-use survey of four large Canadian hospitals, from the Canadian Institute for Health Information (CIHI), and from the Canadian economic literature. Case-mix information obtained from CIHI was incorporated into the cohort deterministic model, which predicted the number of VTEs and bleeds following prophylaxis with fondaparinux or enoxaparin within 90 days of surgery, and the associated overall cost difference. The stability of the base-case findings was evaluated with sensitivity analyses.Study perspectiveCanadian healthcare system perspective.Main outcome measures and resultsAssuming a case mix of 50 693 major hip or knee surgeries performed in Canada in 1999/2000 (as reported by CIHI), the model predicted that prophylaxis with fondaparinux would avoid an additional 16 symptomatic VTEs per 1000 patients over the first 90 days, with an average cost savings of

Reliability, validity and ease of use of a portable point-of-care coagulation device in a pharmacist-managed anticoagulation clinic.

Can55 per patient. These findings were stable when key economic and clinical parameters were varied, including bleeding events.ConclusionsOur results suggest that in Canada, prophylactic fondaparinux compared with enoxaparin avoids VTEs and is associated with lower costs in patients who undergo major hip or knee surgery.

Evaluation of a continuous quality improvement program in anticoagulant therapy: Feasibility, satisfaction and perception.

AbstractIn a pharmacist-managed anticoagulation clinic, portable point-of-care coagulation devices may facilitate patient monitoring by providing rapid INR measurement. Few studies, however, have validated this type of device. Objective: To evaluate the reliability, validity and ease of use of the CoaguChek S, a new portable coagulation device. Methods: A total of 100 patients followed at a pharmacist-managed anticoagulation clinic attended two study visits. INRs were measured using the CoaguChek S and the standard laboratory technique. Results: Reliability: The test-retest reliability (precision) of the CoaguChek S, estimated by the intraclass correlation coefficient (ICC) and a 95% confidence interval (95% CI), was high (0.98 (0.98–0.99)) and comparable to the standard laboratory technique (0.99 (0.98–0.99)). Interrater reliability was also high (0.97 (0.95–0.98)). Reliability coefficients did not vary with the test-strip lot number nor the CoaguChek S operator. Validity: When compared with standard laboratory procedure, the ICC (95% CI) was equal to 0.93 (0.91–0.95). The mean difference (95% CI) between INR measured by the laboratory and the CoaguChek S was equal to −0.02 units (−0.06–0.03). The mean absolute and relative absolute differences (95% CI) were equal to 0.24 units (0.21–0.27) and 9% (8%–10%), respectively. Differences tended to increase for INRs greater than 3 units as seen by a mean difference (95% CI) of −0.17 units (−0.35–0.02). This represented a mean absolute difference (95% CI) of 0.44 units (0.33–0.55) and a mean relative absolute difference of 12% (9%–15%). Concordance between therapeutic decisions based on CoaguChek S and laboratory results was high (Kappa = 0.68). In 34 cases (18%), the therapeutic decision would have been different. However, in 15 of these discordant observations, the difference between the CoaguCheck S and laboratory INR was ≤0.25 units. Ease of use: In 3% of cases, no INR could be measured by the CoaguChek S. The percentage of extra finger pricks and extra test-strips were equal to 25.8% and 23.7%, respectively. Conclusion: When used by health professionals in a pharmacist-managed anticoagulation clinic, the CoaguChek S is reliable, valid and easy to use. However, its validity tends to decrease as the INR increases, possibly due to the low sensitivity of the thromboplastin. If the CoaguChek S INR is supratherapeutic, we would therefore recommend confirming the results with a standard laboratory measurement.

Implementation and evaluation of a pharmacy-led thromboprophylaxis campaign in a community hospital.

Background: The ACO Program (Programme ACO), a continuous quality improvement program (CQIP) in anticoagulation therapy, was offered in community pharmacies as a pilot project. Objective: To evaluate the participants’ appreciation for the various activities of the program. Methods: Participants had access to training activities, including an audit with feedback, online training activities (OTA), clinical tools and support from facilitators. Cognitive behavioural learning determinants were evaluated before and 5 months after the beginning of the program. Participants’ satisfaction and perception were documented via online questionnaires and a semistructured interview. Results: Of the 52 pharmacists in the ACO Program, 47 participated in this evaluation. Seventy-seven percent of the participants completed at least 1 OTA and 6% published on the forum. The feeling of personal effectiveness rose from 8.01 (7.67-8.35) to 8.62 (8.24-8.99). The audit and feedback, as well as the high-quality OTA and their lecturers, were the most appreciated elements. Discussion: There was a high OTA participation rate. The facilitators seemed to play a key role in the CQIP. The low level of participation in the forum reflects the known phenomenon of social loafing. Technical difficulties affecting the platform and data collection for the audit with feedback constituted limitations. Conclusion: The CQIP in anticoagulation therapy is appreciated by community pharmacists and is associated with an improved feeling of personal effectiveness.

Dosage of enoxaparin among obese and renal impairment patients

In hospitalized patients, venous thromboembolism (VTE) is an important cause of morbidity and mortality. Despite evidence demonstrating efficacy and safety of pharmacological thromboprophylaxis in the prevention of VTE, its use remains low. The aim of this study is to compare the incidence of use of thromboprophylaxis before and after a pharmacy-led thrombosis prevention campaign in medical patients hospitalized in a community hospital. A pharmacy-led multifaceted thromboprophylaxis campaign including continuing education activities for physicians and pharmacists and individualized academic detailing activities supported by clinical tools were implemented over an 8-week period. In a quasi-experimental study, the incidence of pharmacological thromboprophylaxis was evaluated using a retrospective chart review and compared before and after the campaign in medical patients at high and non-high risk of VTE as defined by the American College of Chest Physicians criteria. The medical charts of 461 patients were reviewed; 66 and 58 patients were at high-risk of VTE prior to and after the campaign, respectively. After the campaign, thromboprophylaxis ordering in high-risk patients increased from 15.2 to 43.1% (adjusted OR: 6.8; 95% CI: 2.5–18.0). Thromboprophylaxis ordering in non-high risk patients was 1.8% before the campaign and 6.0% after. This increase was not statistically significant (adjusted OR: 4.6; 95% CI: 1.0–20.4). The incidence of pharmacologic thromboprophylaxis in hospitalized medical patients at high-risk of VTE increased significantly after the campaign but remained sub-optimal. Longer or a different campaign may be needed to ensure long-term optimal thromboprophylaxis use.