Adding Pharmacists to Core Hemophilia Care Teams Improves Outcomes, Patient Costs

Making pharmacists part of a comprehensive hemophilia care model may improve bleeding outcomes, medication access and adherence, and lead to cost savings, according to findings from a recent study published in The Permanente Journal. The National Hemophilia Foundation (NHF) guidelines for such a model do not currently include a clinical pharmacist.

Implementing a multidisciplinary care team for patients with hemophilia may improve disease management overall, and the NHF-McMaster Guideline on Care Models for Hemophilia Management conditionally recommends that care teams include a range of specialists to improve outcomes: a hematologist, nurse hemophilia specialist, physical therapist, social worker, and specialized coagulation laboratory.

“The goals of such programs are reducing overall bleed rates, patient and family education on appropriate factor dosing, addressing barriers to factor use, coordinating perioperative care, and improving quality of life and overall survival,” the authors wrote. “However, there is little published evidence evaluating the impact of these team members on clinical outcomes, and pharmacists are often not included in the above list of core hemophilia specialists.”

The study evaluated a systems-based quality improvement initiative involving 15 medical center service areas that included pharmacists on core management teams for hemophilia. Pharmacists at a centralized location were added to the care teams and provided telemedicine services to patients. They took comprehensive bleeding histories and developed plans for prophylactic treatment, pre- and postsurgical management, and plans for coagulation factor replacement during episodes of bleeding.

The pharmacists provided additional touch points for patients between follow-up visits, ordered specialized labs for providers, and tailored patients’ medication selections. To minimize product waste, the pharmacists could access vendor inventories to personalize factor vial sizes to best fit a patient’s target dose, and a factor recycling program was implemented to track and dispense unused products with impending expiration dates to patients on regular prophylaxis.

The retrospective analysis assessed patient outcomes and drug costs for 110 patients enrolled in the hemophilia pharmacy service between March 2017 and February 2019 and compared them with data from before and after the program, including March 2016 to February 2020. Bleed rate was calculated as incidence of new bleeds per 100 patient-years, and medication possession ratio (MPR)—the percentage of days that a patient has access to medication within a time frame—was also calculated.

During the program, the annual bleed rate, hospitalizations, and emergency department (ED) visits showed downward trends. The bleed rate was reduced to 37.6 from 40 per 100 patient-years, ED visits dropped from 22.7 to 18.3 per 100 patient-years, and hospitalizations dropped from 6.4 to 3 per 100 patient-years.

“The improvement in communication and additional touch points added by the pharmacy specialists led to earlier identification of bleeds and therapy being administered in the clinic rather than the ED,” the authors wrote. “A reduction in ED visits reduces the overall cost of care for members by affecting copayments, as well as utilization of emergency services within the health care system.”

The number of patients adherent to prophylactic treatment trended upward, and the personalized vial sizes and recycling program significantly reduced waste. In the prestudy period, 9 patients of the 18 on regular prophylaxis (50%) had an MPR of at least 80%, while 11 patients (61%) had and MPR of at least 80% in the poststudy period.

The cost-savings for medication over a 12-month period while the program was ongoing amounted to approximately $900,000. Researchers factored in the conversion of 10 patient therapy regimens to emicizumab, a novel, fixed-dose treatment option, over the study period. Emicizumab is a more expensive prophylactic therapy option for patients with hemophilia A that is subcutaneously rather than intravenously administered.

Overall, the findings suggest that adding clinical pharmacists with hemophilia expertise to care teams may improve medication adherence and outcomes for patients with hemophilia. While the findings regarding clinical outcomes were not statistically significant, the authors attribute this to the small cohort size and baseline involvement of a comprehensive care team prior to the addition of pharmacists. The authors concluded that the model may also benefit other integrated health care systems.

“Pharmacists added tangible value to the care of hemophilia patients and were able to provide stability in patients’ care during transient periods of core team staffing turnover, given their expertise overlapped that of other core team members,” the authors wrote. “Future studies may explore the value of core team members in a randomized fashion to establish the cost effectiveness of their impact on quality of life and clinical bleeding outcomes.”

Reference

Lee D, Le AO, Meganck M, Chamberland S, Pai A. Adding a clinical hemophilia pharmacist to the hemophilia comprehensive care model improves health care-related outcomes and drug-related costs in an integrated health care system. Perm J. Published online August 21, 2022. doi:10.7812/TPP/21.192