Thromboembolism has long loomed large on the healthcare landscape, striking more than a million Americans every year and imposing enormous economic and health burdens in almost every clinical setting. Traditional anticoagulants such as warfarin are the cornerstone for treatment of thromboembolic disease management and prevention, but they can be challenging to work with: they must be carefully monitored and often interact with food or other drugs. Newer anticoagulants are more convenient and can be equally effective but they are imperfect, with high-quality evidence just emerging. Regardless of approach, abnormal clotting associated with transitions of care has been particularly intractable. Thus, despite a surge in new knowledge and therapies, clinical outcomes have not improved significantly.
The Department of Medicine has taken on this challenge with the Anticoagulation and Clinical Thrombosis Service. This innovative outpatient program is transforming anticoagulation therapy with a multifaceted strategy, reflecting the Department’s academic nature, including clinical care, education, and research. This strategy extends to both the traditional mainstay anticoagulants, like warfarin, and to novel oral anticoagulants, always driven by evidence and focused on quality – the unifying elements throughout the service.
This comprehensive anticoagulant management is on its way toward building a top-tier research enterprise focusing on thromboembolism. More than just providing superior care, it is also serving to guide and educate clinicians across the Health System.
Director Alex C. Spyropoulos, MD, is widely recognized for advancing the development of protocols for treatment of thrombosis. Recruited to North Shore-LIJ in early 2013 to establish a center of excellence in coagulation and clinical thrombosis, he is overseeing an unprecedented expansion of the service that will place it among the nation’s largest and most productive services.
The program’s flagship site at Staten Island University Hospital has long been a national leader in standardizing management of thromboembolic conditions and developing novel anticoagulation strategies. Its services include outpatient-based treatment of venous thromboembolic disease, warfarin patient self-testing, and perioperative “bridging” for patients on chronic anticoagulation.
That success is being leveraged across North Shore-LIJ Health System, with the newest site at Huntington Hospital, the largest anticoagulation service on Long Island. An interdisciplinary team of physicians and nurse practitioners collaborates with each patient’s primary care provider, cardiologist, or other referring physician to maximize the efficacy and safety of anticoagulant medications, by managing their anticoagulation and clinical thrombotic care. The service brings state-of-the-art evidence to clinicians working on the front lines with routine patients as well as those at higher risk of abnormal clotting or in high-risk situations, such as surgery, with special emphasis on transitions across care settings. In less than a year at North Shore-LIJ, Dr. Spyropoulos has developed the first System-wide validated warfarin dosing nomogram. This is implemented throughout the Health System to standardize care and ensure quality. Department Chair Dr. Thomas McGinn noted, “This is really remarkable: for the first time ever an entire health system is using an evidence-based warfarin dosing nomogram. With Alex, we are well on the way to becoming a national leader in thrombosis treatment and prevention.”
At the same time, Dr. Spyropoulos is overseeing a remarkable range of research initiatives in clinical thrombosis and management, continuing his landmark studies as well as launching new projects that use North Shore-LIJ’s unique resources. At press time, the service had been operating in its current form for only eleven months but already has six high-profile, well-funded projects underway, with support from government and pharmaceutical firms. A major ongoing study on perioperative bridging is supported by the National Heart, Lung and Blood Institute of NIH, and Dr. Spyropoulos is continuing his work on validating the risk model for his clinical prediction study on thrombosis development in the hospital. Dr. Spyropoulos is a co-principal investigator of MARINER, a global Phase 3 study of medical thromboprophylaxis with rivaroxaban using the IMPROVE risk model, derived by his team in 2010. The trial involves 8,000 patients at 500 medical centers in 25 countries.
Dr. Spyropoulos has extraordinarily wide-ranging research experience, including serving as principal investigator or member of the scientific committee, steering committee, data safety monitoring board for multiple international, multicenter outcome and clinical studies in thrombosis. But he expresses particular enthusiasm for building an unparalleled research enterprise at North Shore-LIJ, including both outcomes research and clinical trials research, adding, “The size and diversity of the patient population are simply unmatched, with unlimited potential for impact.”