PB0606 - Bone Health Screening for Pediatric Patients on Chronic Warfarin Therapy: A Quality Improvement Initiative

Monday, June 24, 2024

13:45 – 14:45 ICT

Room: Exhibition Hall

Co-Author(s)

NB

Natasha Bala

MD, Hemostasis and Thrombosis Fellow
Rady Children's Hospital
San Diego, California, United States
JS

Joseph Stanek, MS

MS
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
TC

Tara C. Cosgrove

MD
Division of Cardiology, Nationwide Children's Hospital/The Ohio State University
Columbus, Ohio, United States
KV

Katherine Vasko

CPNP-AC
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
CW

Courtney Wiseman

FPN
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
KM

Kay Monda

RN
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
JC

Joan Canini

RN
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
NL

Nichole Lizak

RN
Hematology-Oncology/BMT Nationwide Children’s Hospital, Columbus OH
Columbus, Ohio, United States
JM

John D. Mahan

MD
Division of Nephrology and Hypertension, Nationwide Children's Hospital
Columbus, Ohio, United States

Presenting Author(s)

Vilmarie Rodriguez, MD, MS

Director Thrombosis and Anticoagulation Program
Nationwide Children's Hospital/The Ohio State University
Columbus, Ohio, United States

Background: Several studies have reported the association of low bone mineral density (BMD) in pediatric patients on chronic warfarin anticoagulation.

Aims: Increase the percentage of < 21 years old patients on chronic warfarin (> 6 months) who receive a Dual-energy X-ray absorptiometry (DEXA) scan from 4% to 20% and monitoring for Vitamin D deficiency from 25 to 50%, from January 2022 to December 2023 using quality improvement (QI) methodology.

Methods: The Institute for Healthcare Model for Improvement was used to improve bone health surveillance for pediatric patients on chronic warfarin therapy. Cardiology, hematology, and nephrology team stakeholders developed a key driver diagram with interventions addressing barriers to bone health screening.

Results: Fifty-six patients on chronic warfarin patients were identified, 60.7% (n=34) were male and the median (range) age at the start of warfarin therapy was 7.5 years (3.3, 11.1) (Table 1). Thirty-four patients completed bone density imaging studies (60.7%) with 25% (n=14) having normal to low normal bone densities (z score -1.0- 0.0), 48.4% (n=15) osteopenia (z-score < -1.0), and 6.5% (n=2) osteoporosis (z-score < -2.0). 62.5% (n=35) completed vitamin D testing with low levels ( < 30 ng/ml) reported in 56.5% (n=16). Ten patients (21.7%) reported a history of bone fractures. Longer duration of warfarin therapy was found to be significantly associated with low BMD [normal/low normal n=14: median 30 months (20,51) vs osteopenia/osteoporosis n=17; median 105 months (88,108), p 0.040] (Table 2). Bone density screening improved from 4% to 55.3% and vitamin D monitoring from 25% to 62.5%.

Conclusion(s): Pediatric patients on chronic warfarin therapy are at risk for low BMD with over half having abnormal bone density and vitamin D levels, placing them at higher risk for bone fractures. Bone health screening is imperative to prevent low BMD which can lead to bone fractures.