An “Army of Specialists” Needed for Anticoagulation Stewardship Programs

For Allison Burnett, anticoagulation was her destiny. Although she was a self-described late bloomer, starting pharmacy school at age 28, she seemed to be always at the right place at the right time to take advantage of opportunities that led her toward a career in anticoagulation.

“I love the challenges that I face every day in caring for patients who require these really essential, high-alert medications,” she said. “I love building systematic processes and finding solutions to deliver high-quality care to patients, and all of that requires a high degree of multidisciplinary teamwork.”

An anticoag specialist
Burnett is now recognized as an expert in the field. A longtime ASHP member and lead pharmacist for the Inpatient Antithrombosis Stewardship program at the University of New Mexico (UNM) Hospital in Albuquerque, Burnett has published more than 50 peer-reviewed articles and book chapters on anticoagulation, thrombosis, and bleeding management. She has presented on these topics at numerous national and international conferences, including the ASHP 2023 Midyear Clinical Meeting & Exhibition, and led roundtable discussions on anticoagulation stewardship for ASHP through the Section of Clinical Specialists and Scientists.

Additionally, she teaches at the UNM College of Pharmacy, sits on the National Certification Board for Anticoagulation Providers, and is president of the Anticoagulation Forum (AC Forum), a national nonprofit organization dedicated to educating and empowering clinicians to optimize stewardship of anticoagulant therapies.

Anticoagulants are used by more than 8 million people in the United States, she said, yet surveillance data from the Centers for Disease Control and Prevention (CDC) indicate they also are the leading cause of patient harm leading to emergency department visits and hospital readmissions due to inappropriate prescribing and management.

Anticoagulation stewardship
Just as antimicrobial stewardship has become a recognized paradigm shift in care delivery, Burnett and others with the AC Forum are working to turn anticoagulation management techniques from just drug management to full stewardship and overall disease state management. Developing protocols, guidelines, and systematic processes around the medications “makes everybody’s job easier to do the right thing…and allows us to deliver the best care that we can to our patients.”

During pharmacy school, Burnett completed a rotation in her hometown of Clovis, New Mexico, with a family friend who owned a community pharmacy and did consulting work for nursing homes in the area. This preceptor assigned Burnett a project evaluating local provider adherence with then-published CHEST 2001 guidelines on oral anticoagulation therapy, which “were abysmal, well below 20%,” she said.

She used that project during a presentation when interviewing for a postgraduate year 1 (PGY1) pharmacy residency at Boston Medical Center, where she matched and learned more under well-known anticoagulation and cardiology pharmacist Toby Trujillo and from Jack Ansell, the founder of the AC Forum and then the medical director of the Boston Medical Center’s anticoagulation clinic where she had a rotation.

She later returned to New Mexico and took a position with Lovelace Medical Center in Albuquerque, where she worked under anticoagulation experts Alex Spyropoulos and Kurt Mahanand, who helped start one of the region’s first acute care anticoagulation management programs. In 2006, she moved to the University of New Mexico Hospital, where internationally known anticoagulation expert David Garcia mentored her.

“It’s very interesting how I got involved with anticoagulation early on, and it seemed to be my destiny at every turn,” Burnett said. “I’m extremely grateful for all of the opportunities I have been afforded and for the amazing individuals who have helped me along the way.”

Appropriate prescribing
Today, Burnett focuses on ensuring that anticoagulants are used and prescribed appropriately at the local level through her role at the University of New Mexico Hospital and nationally through the AC Forum.

As many as one of every four patients on a direct oral anticoagulant are on the inappropriate dose or frequency, she added: “These agents aren’t always straightforward to dose based on a patient’s characteristics or drug interactions.” Other issues with anticoagulants she and her colleagues commonly see include challenges with warfarin management, high rates of errors with heparin infusions, and challenges with the management of blood thinners around invasive procedures. Now, a new class of anticoagulants, factor XIa inhibitors, is emerging. It’s all the more reason why pharmacists — the drug experts — have to be involved in prescribing and management of these agents, she said.

“In the last 10 years, we’ve doubled the number of anticoagulant and antiplatelet medications, and we’ve increased the number of reversal agents available,” Burnett said. “All of that leads to a high degree of complexity.” Trends like an aging population and the obesity epidemic are leading to increased rates of atrial fibrillation and venous thromboembolism. “The number of people requiring anticoagulants is going to at least double in the next couple of decades. We truly have an impending public health crisis coming down the pike.”

The AC Forum, for the past five years, has been working to promote anticoagulation stewardship efforts with agencies including the Food and Drug Administration, Centers for Medicare and Medicaid Services, and CDC, with the goal of making it a federal-level mandate. And, to gear up, since Burnett became president (the first female and first pharmacist to hold that position) in 2021, she and several pharmacist colleagues began efforts to create a specialty pharmacy residency in thrombosis and hemostasis management.

Creating an army of specialists
The one-year, postgraduate year 2 (PGY2) program, accredited by ASHP, is now running in eight locations across the country, with the AC Forum providing grant funding to launch seven of those programs to date. Residents and program directors from each program participate in monthly educational webinars in which residents present challenging cases so all can learn. The AC Forum’s funding should eventually cover training for some 20 PGY2 pharmacists.

“We need to create this army of specialists to step into these anticoagulation stewardship programs as they’re being stood up around the country,” Burnett said. “We’re seeing more and more jobs being posted looking for these types of specialized pharmacists. Because pharmacists do anticoagulation so well, they can serve as both the frontline, boots-on-the-ground drivers of clinical initiatives and as the leaders and faces of those anticoagulation stewardship programs.”

Burnett encouraged others to get involved in the field. “Anticoagulation and antithrombosis is an area ripe with opportunity,” she said. “Start exploring this field. Students can do this on rotation, by asking their preceptors questions, volunteering, and taking on projects centered around anticoagulation or antithrombosis stewardship.”

She also recommended getting involved with anticoagulation efforts through ASHP and the AC Forum, which has volunteers ranging from pharmacy students to seasoned professionals: “We’re always looking for volunteers to help us grow and progress the organization.”