How albumin administration for cirrhosis impacts on hospital albumin consumption and expenditure

Abstract

To assess the impact of guidelines for albumin prescription in an academic hospital, which is a referral center for liver diseases. Although randomized trials and guidelines support albumin administration for some complications of cirrhosis, the high cost of albumin greatly limits its use in clinical practice. In 2003, a multidisciplinary panel at Sant'Orsola-Malpighi University Hospital (Bologna, Italy) used a literature-based consensus method to list all the acute and chronic conditions for which albumin is indicated as first- or second-line treatment. Indications in hepatology included prevention of post-paracentesis circulatory dysfunction and renal failure induced by spontaneous bacterial peritonitis, and treatment of hepatorenal syndrome and refractory ascites. Although still debated, albumin administration in refractory ascites is accepted by the Italian health care system. We analyzed albumin prescription and related costs before and after implementation of the new guidelines. While albumin consumption and costs doubled from 1998 to 2002, they dropped 20% after 2003, and remained stable for the following 6 years. Complications of cirrhosis, namely refractory ascites and paracentesis, represented the predominant indications, followed by major surgery, shock, enteric diseases, and plasmapheresis. Albumin consumption increased significantly after guideline implementation in the liver units, whereas it declined elsewhere in the hospital. Lastly, extra-protocol albumin prescription was estimated as < 10%. Albumin administration in cirrhosis according to international guidelines does not increase total hospital albumin consumption if its use in settings without evidence of efficacy is avoided.