Skip to main content
SpringerLink
Log in

A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

Heparin Induced Thrombocytopenia (HIT) is a serious complication from administration of heparin products. The 4T score is a validated pre-test probability tool to screen for HIT in hospitalized patients. As the negative predictive value (NPV) is very high further testing for HIT in patients with a low score can be avoided. Our objective was to determine trends at our hospital with respect to utilization of HIT antibody (HITAb) testing and evaluate economic burden from unnecessary HIT testing. A retrospective cohort review was performed on patients age 18 and above admitted to a tertiary care center from February 2013 to December 2014 who underwent HITAb testing. Surgical ICU patients were excluded. Patients were stratified into low, intermediate, and high risk for HIT based on the 4T model. Statistical analysis was performed using Chi square and regression models. Of 150 patients that underwent HITAb testing, 134 met inclusion criteria. 73 were male (54.47 %) and mean age was 55.50 ± 17.27 years. 81 patients had a low 4T score 0–3. Analysis of testing trends showed 60.44 % of patients were tested for HITAb despite being low risk using the 4T model. Only three patients with low 4T score were positive on confirmatory SRA testing (NPV 96.29 % CI 95 = 89.56–99.23 %). Expenditure due to inappropriate testing and treatment was estimated at $103,348.13. The majority of HITAb testing was found unnecessary based on the investigator calculated 4T score. We propose implementation of an electronic medical record (EMR) based calculator in order to reduce unneeded tests and reduce use of costlier alternative anticoagulants.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

CCU:

Coronary Care Unit

EMR:

Electronic medical record

ELISA:

Enzyme-linked immunosorbent assay

HIT:

Heparin Induced Thrombocytopenia

HEP:

HIT expert probability

ICU:

Intensive care unit

PF-4:

Platelet factor 4

O.D.:

Optical density

SRA:

Serotonin release assay

SICU:

Surgical Intensive Care Unit

References

  1. Kelton JG, Warkentin TE (2008) Heparin-induced thrombocytopenia: a historical perspective. Blood 112(7):2607–2616

    Article  CAS  PubMed  Google Scholar 

  2. Rauova L, Zhai L, Kowalska MA, Arepally GM, Cines DB, Poncz M (2006) Role of platelet surface PF4 antigenic complexes in heparin-induced thrombocytopenia pathogenesis: diagnostic and therapeutic implications. Blood 107(6):2346–2353

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Rauova L, Poncz M, McKenzie SE, Reilly MP, Arepally G, Weisel JW et al (2005) Ultralarge complexes of PF4 and heparin are central to the pathogenesis of heparin-induced thrombocytopenia. Blood 105(1):131–138

    Article  CAS  PubMed  Google Scholar 

  4. Sachais BS, Litvinov RI, Yarovoi SV, Rauova L, Hinds JL, Rux AH et al (2012) Dynamic antibody-binding properties in the pathogenesis of HIT. Blood 120(5):1137–1142

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Greinacher A, Potzsch B, Amiral J, Dummel V, Eichner A, Mueller-Eckhardt C (1994) Heparin-associated thrombocytopenia: isolation of the antibody and characterization of a multimolecular PF4-heparin complex as the major antigen. Thromb Haemost 71(2):247–251

    CAS  PubMed  Google Scholar 

  6. Warkentin TE (1999) Heparin-induced thrombocytopenia: a clinicopathologic syndrome. Thromb Haemost 82(2):439–447

    CAS  PubMed  Google Scholar 

  7. Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M et al (1995) Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 332(20):1330–1335

    Article  CAS  PubMed  Google Scholar 

  8. Girolami B, Prandoni P, Stefani PM, Tanduo C, Sabbion P, Eichler P et al (2003) The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study. Blood 101(8):2955–2959

    Article  CAS  PubMed  Google Scholar 

  9. Martel N, Lee J, Wells PS (2005) Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 106(8):2710–2715

    Article  CAS  PubMed  Google Scholar 

  10. Linkins LA, Dans AL, Moores LK, Bona R, Davidson BL, Schulman S et al (2012) Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e495S–e530S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Warkentin TE (2011) How I diagnose and manage HIT. ASH Educ Program B 1:143–149

    Google Scholar 

  12. Warkentin TE, Kelton JG (1996) A 14-year study of heparin-induced thrombocytopenia. Am J Med 101(5):502–507

    Article  CAS  PubMed  Google Scholar 

  13. Warkentin TE, Greinacher A, Koster A, Lincoff AM (2008) Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6 Suppl):340S–380S

    Article  CAS  PubMed  Google Scholar 

  14. Warkentin TE (2012) HIT: treatment easier, prevention harder. Blood 119(5):1099–1100

    Article  CAS  PubMed  Google Scholar 

  15. Patrick AR, Winkelmayer WC, Avorn J, Fischer MA (2007) Strategies for the management of suspected heparin-induced thrombocytopenia: a cost-effectiveness analysis. Pharmacoeconomics 25(11):949–961

    Article  PubMed  Google Scholar 

  16. Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A (2006) Evaluation of pretest clinical score (4 T’s) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 4(4):759–765

    Article  CAS  PubMed  Google Scholar 

  17. Cuker A, Gimotty PA, Crowther MA, Warkentin TE (2012) Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 120(20):4160–4167

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Chaturvedi S, Kohli R, McCrae K (2015) Over-testing for heparin induced thrombocytopenia in hospitalized patients. J Thromb Thrombolysis 40(1):12–16

    Article  CAS  PubMed  Google Scholar 

  19. Cuker A (2011) Heparin-induced thrombocytopenia (HIT) in 2011: an epidemic of overdiagnosis. Thromb Haemost 106(6):993–994

    Article  CAS  PubMed  Google Scholar 

  20. Cuker A, Cines DB (2012) How I treat heparin-induced thrombocytopenia. Blood 119(10):2209–2218

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The study was funded by a grant provided by the University of Nevada School of Medicine, Office of Medical Research. Funding source had no role in study design, conduct of study, collection, management, analysis, or interpretation of data; or in review, preparation, and approval of the manuscript.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, University of Nevada School of Medicine, 1701 W Charleston Blvd., #230, Las Vegas, NV, 89102, USA

    Mohanad Hasan, Pannaga Malalur, Manas Agastya, Ali O. Malik, Yaser Dawod, Mohammad Jaradat, Ji-Won Yoo & Ranjit Makar

Authors
  1. Mohanad Hasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pannaga Malalur
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Manas Agastya
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ali O. Malik
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yaser Dawod
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mohammad Jaradat
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ji-Won Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ranjit Makar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Pannaga Malalur.

Ethics declarations

Conflict of Interest

None

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hasan, M., Malalur, P., Agastya, M. et al. A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score. J Thromb Thrombolysis 42, 441–446 (2016). https://doi.org/10.1007/s11239-016-1396-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-016-1396-6

Keywords

Search

Navigation