Staged Interventions to Improve Quality and Reduce Cost of Care in Patients with Suspected Heparin-Induced Thrombocytopenia

Background

Heparin induced thrombocytopenia (HIT) is a rare but often considered diagnosis that requires treatment, in the form of costly parenteral anticoagulants, while awaiting the results of confirmatory testing. We hypothesized that improving the accuracy and consistency with which a patient's risk of HIT was determined, through the use of Computer-based Provider Order Entry (CPOE) interventions, would lead to decreased cost of care.

Methods

This study was conducted out of two affiliated US academic medical centers with a shared electronic medical record (EMR). A series of staged interventions, including provider and pharmacist education, real-time alerts and a CPOE based decision support tool were implemented as part of a multidisciplinary quality improvement project between January 1, 2013 and December 31, 2013. All inpatients ³18 years of age who underwent laboratory testing for HIT and/or were started on bivailrudin therapy for suspected HIT between January 1, 2012 and December 31, 2014 were included. For the purposes of our study, we defined the pre-intervention period as January 1 through December 31, 2012 and the post-intervention period as January 1 through December 31, 2014. The primary outcome was mean monthly bivalirudin expenditure at each institution. The secondary outcomes were number of HIT enzyme-linked immunosorbent assay (ELISA) and serotonin release assay (SRA) tests sent per month.

Results

We observed a statistically significant reduction in mean monthly bivalirudin expenditures from $64,178 to $17,704 (p = 0.0002) at one of the included centers and a decrease that approached significance from $28,275 to $16,708 (p = 0.100) at the other. Statistically significant reductions were also noted in mean monthly ELISA testing rates from 38.1 to 19.8 (p=0.01) and mean monthly SRA testing rates from 9.4 to 3.1 (p=0.0001) across both centers.

Discussion

Our findings suggest that the use of a computer-based order entry intervention, as part of a multidisciplinary quality improvement effort, can effectively reduce cost and decrease rates of lab testing in the management of heparin-induced thrombocytopenia. Such interventions are relatively low cost and of low complexity in institutions with established order entry systems and have the potential for a lasting impact on cost and quality of care.