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Critical Care Specialist, Department of Pharmacy Practice; Clinical Assistant Professor, College of Pharmacy and Health Sciences Center, Mercer University, Atlanta, GA
Medication Use Evaluation/Adverse Drug Reaction Coordinator, Pharmacy CARE Team, University of Colorado Hospital; Clinical Assistant Professor and Drug Information Externship Co-Preceptor, School of Pharmacy, University of Colorado–Denver, Aurora, CO
Critical Care Clinical Pharmacy Specialist, University of Colorado Hospital; Associate Professor, School of Pharmacy, University of Colorado–Denver
Medication Policy/Business Coordinator, Pharmacy CARE Team; Co-Chair, Pharmacy and Therapeutics Committee, University of Colorado Hospital, Aurora
Chairman, Pharmacy and Therapeutics Committee, University of Colorado Hospital; Professor of Pulmonary Sciences, School of Medicine, University of Colorado–Denver
Reprints: Dr. Golightly, Health Sciences Library/Center for Drug Information, Education, and Evaluation–Campus Box A-003, 12950 E. Montview Blvd., PO Box 6508, Aurora, CO 80045, fax 720/848-4190, larry.golightly{at}uch.edu
BACKGROUND: Recombinant human coagulation factor VIIa (rVIIa) is a procoagulant indicated for treatment of bleeding in patients with hemophilia. A large proportion of rVIIa utilization is for off-label administration in nonhemophiliac patients with acute hemorrhage. Concerns of potentially inappropriate use, safety, and cost of rVIIa led to efforts to standardize use of this agent.
OBJECTIVE: To comparatively describe the utilization of rVIIa upon implementation of an evidence-based guideline at a university hospital.
METHODS: With advisory direction from a multidisciplinary task force, an evidence-based guideline for use of rVIIa was developed, approved, and fully implemented. Assessment of appropriateness of use and retrospective review were required for all cases. Effects of these actions were evaluated by auditing and comparing rVIIa use in patients treated in two 6-month observation periods before and after guideline implementation. Outcomes assessed were proportions of patients deemed appropriate to receive rVIIa, compliance with dosing recommendations, and acquisition costs.
RESULTS: Twenty-two and 29 patients were treated in the periods before and after guideline implementation, respectively. Patient characteristics were similar, except more cardiothoracic surgeries were performed in patients treated before implementation of the guideline. Indications for rVIIa use were judged appropriate in 21 (95.5%) before-cases and in all (100%) after-cases. The dose was compliant in 1 (4.6%) before-case and 27 (93.1%) after-cases (p < 0.001). Mean dosages of rVIIa administered were 81.8 µg/kg and 45.3 µg/kg in before- and after-cases, respectively (p < 0.001). During the respective periods of observation, amounts of rVIIa purchased monthly averaged 42.6 mg and 21.8 mg, a 49% difference. Semiannual expenditures for rVIIa decreased approximately $110,000 following guideline implementation. Patient outcomes were similar.
CONCLUSIONS: A guideline based on currently available evidence can serve to sustain the clinical appropriateness of rVIIa therapy and substantially decrease costs.
Key Words: formulary management, hemophilia, recombinant human coagulation factor VIIa
Published Online, May 13, 2008. www.theannals.com, DOI 10.1345/aph.1L047
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