Antiplatelet Agents: The Transition that Reduces Cost & Maintains World-class Care

Healthcare today is focused on the Triple Aim: Improving patient quality of care and satisfaction, improving outcomes, while also reducing total cost of care. Cardiology departments are contributing by finding ways to reduce expenses while still offering excellent, evidence-based care. The savings in acquisition costs are significant. The cath lab team at East Carolina Heart Institute at Vidant Medical Center has saved almost $400,000 in drug acquisition costs over the course of a year by transitioning to Aggrastat (tirofiban HCl) as their preferred glycoprotein IIb/IIIa inhibitor. Director of the Cardiac Catheterization Laboratories, Ramesh Daggubati, MD, led the initiative. As he told Cardiovascular Business, making the transition is something cardiology teams across the country should consider. He recommends sharing evidence, supporting the transition with physicians and pharmacists, and sharing the potential drug acquisition costs savings with administration.

There is a current focus on providing high-quality healthcare, while reducing costs. How important is it now for physicians/healthcare professionals to take this into consideration?

All physicians are trying their best to obtain the optimal result for the patient. At the same time, with the increasing cost of healthcare in the United States, we are paying great attention to the cost of the care that we are providing. That is the reason that our institution looked at tirofiban.

How does your cath lab team approach the clinical and economic challenges with treatment decisions when it comes to preferred pharmacological therapies? 

In our cath lab, at one time, we had all the three glycoprotein IIb/IIIa inhibitors (GPI) available to us. We discussed, together with all the physicians and pharmacy champions, whether the physicians believed that one medication has an advantage over the other and nobody could come up with information that ReoPro (abciximab), or Integrilin (eptifibatide) is superior to tirofiban in achieving the results that we wanted. When we showed them the numbers of decreasing the acquisition cost of medications in the cath lab, everybody immediately agreed. That's how we moved to tirofiban.

Who is directly involved in making these decisions for the cath lab? How do you work with other departments such as pharmacy to make the best decisions for patients and the cath lab?

As the director, I am involved in making decisions, but I do take consideration from all the physicians. If they're completely against making a change, and they're able to present the data properly, we will reconsider. But if they don’t have any objection to a change, we move forward. Administrators are informed and present when we discuss various decisions for the cath lab, however, they do not vote on clinical matters.

In this case, we based our decision on the evidence with all the clinical studies on tirofiban. We initially had a presentation by our pharmacy champion and myself, for all of the physicians that use the cath lab showing:

• What the guidelines say in terms of the use of GPIs.
• What the studies support: The use of tirofiban against abciximab and the reduction in bleeding with tirofiban, as compared to abciximab.
• Our market share and acquisition cost of medication per patient. We showed that in our institution, we could probably save anywhere between $125,000 to nearly $400,000 per year in acquisition costs.

Then we said, “Could we transition to tirofiban? And could we limit our GPI's to shorten infusion duration? At the end of the presentation, we took a vote among all physicians, and they all agreed. Unanimously, we came to a decision to transition to tirofiban.

The pharmacy was supportive of our decision to transition to tirofiban, and liked the definite savings in acquisition costs associated with making the transition. They didn't have any problem making the medication available to us, and they were directly involved in helping us to facilitate and implement this change.

How has your facility’s transition to tirofiban as the preferred GPI been accepted?

We didn't have a problem at all.

In the cath lab, our coordinator (who is also a cath lab nurse), took it upon herself to be the nursing champion and the pharmacist informed and educated our nurses on the transition from eptifibatide to tirofiban. Our coordinator made sure everyone understood the differences between medications.

The nursing managers went to specific floors and had meetings with all the nurses in our telemetry units and intensive care units. Most of our telemetry floors and intensive care units also have pharmacists on the floor, and so we ensured everyone was properly educated.

How has the reduced cost of tirofiban versus other GPI’s affected reimbursement received by the hospital/physicians?

We haven't heard anything negative, our hospital administrators are happy that reimbursement has remained the same for us.

GPI’s remain an important tool to interventionalists, though they are no longer used routinely. Approximately what percentage of ACS patients receive a GPI at your facility?

At one time, we were using GPI’s in almost 80 to 90 percent of ACS patients, but now about 30 to 40 percent of our ACS patients receive a GPI.

What are the standard infusion lengths being used by you and your fellow interventionalists?

I use a 4 hour infusion with tirofiban, but most of our colleagues use it for up to 12 hours. I use a 4 hour infusion since at 4 hours the newer oral P2Y12 inhibitors have reached sufficient antiplatelet effects such that I now have the option to use a shorter infusion time with tirofiban to potentially reduce bleeding complications.

What advice would you give to other cath labs looking to maintain high-quality care while reducing acquisition costs? And in particular, transitioning to tirofiban as their preferred GPI?

We have definitely been able to show a benefit in terms of reduction of acquisition costs. If other facilities are looking to implement a transition, they should analyze the data for thrombotic complications and costs.

At a higher level, we need to get together as physicians, at national meetings like ACC or AHA or local chapter meetings, and talk about important topics like shorter infusion time with glycoprotein IIb/IIIa inhibitors.