Development of an anticoagulation stewardship program at a large tertiary care academic institution

J Pharm Pract. 2015 Feb;28(1):93-8. doi: 10.1177/0897190013514091. Epub 2013 Dec 10.


Pharmacist-directed anticoagulation management services (AMSs) have been shown to significantly lower anticoagulation-related mortality, length of hospital stay, bleeding complications, blood transfusion requirements, and cost of therapy. AMSs are only 1 component of an anticoagulation stewardship program. Frequently, stewardship programs are limited to inpatient populations. Incorporating components that facilitate transition to outpatient status will ideally encompass complete care. The purpose of this program was to expand anticoagulation services and standardize care by implementing a full-service stewardship program including a transition of care service. The first component of the study involved medication surveillance for inpatients on anticoagulation therapy. The second component involved transitioning patients on anticoagulation, primarily with venous thromboembolism (VTE) to outpatient management. Finally, the pharmacist identified areas for optimization. Optimization involved developing or updating protocols to reflect updates in the literature as well as updating institution-specific information resources. Interventions made through medication surveillance and utilization of the VTE transition of care services translated into a total cost savings of approximately US$270 320. A postgraduate, first-year pharmacy resident contributed to improving patient outcomes while reducing utilization of hospital services and obtaining substantial cost savings through participation in anticoagulation stewardship services.

Keywords: anticoagulation; pharmacist; stewardship.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anticoagulants / administration & dosage*
  • Anticoagulants / therapeutic use
  • Continuity of Patient Care / organization & administration*
  • Drug Utilization Review / organization & administration
  • Female
  • Guideline Adherence
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Patient Discharge
  • Patient Safety
  • Pharmacy Service, Hospital / organization & administration*
  • Practice Guidelines as Topic
  • Quality of Health Care / organization & administration
  • Tertiary Care Centers
  • Venous Thromboembolism / drug therapy*
  • Venous Thromboembolism / prevention & control


  • Anticoagulants