Study of Albumin Use in Liver Diseases at a Tertiary Care Center and Effect of a Computerized Order Set

Abstract

Purpose: Albumin is frequently used for the treatment or prevention of complications of liver cirrhosis. However, albumin is an expensive medication. Albumin use should therefore be evidence-based and appropriate, in order to maximize its value and reduce the risk of complications. The aim was to study the impact of a computerized clinical decision support (CDS) order set on albumin utilization for liver disease in a larger academic tertiary care center. Methods: An appropriate indications list for the use of albumin in liver disease was created based on a systematic review of international guidelines. The appropriate indications for albumin use in liver diseases were deemed to be (1) diagnosis of HRS, (2) treatment of HRS along with vasoconstrictors, (3) large volume paracentesis (>5 litres or Cr >1.5), (4) treatment of SBP only if serum creatinine >1 mg/dL, BUN >30, or total bilirubin >4 mg/dL. A CDS order set was then unveiled throughout the health system that required providers to choose an appropriate indication before order submission. No formal education on appropriate albumin utilization was otherwise given to ordering providers. To assess the impact of the CDS order set alone on albumin utilization in liver disorders, a retrospective chart review of adult in-patients who received albumin 3 months prior to implementation of order set and 3 months post implementation of order set was done. For statistical analysis we used test of the difference in proportions with a p-value of <0.05 considered statistically significant. Results: Pre-order set there were a total of 106 albumin orders (70% appropriate) amounting to 9,498.5 grams of albumin (82% appropriate). Post-order set there were 185 orders (75% appropriate) amounting to 19,295 grams of albumin (84% appropriate). The most common indications for albumin use were large volume paracentesis, diagnosis and treatment of HRS. There was statistically significant improvement in amount of albumin (in grams) used appropriately for large volume paracentesis and treatment of SBP (p<0.001), while there was no difference in number of orders. There was also a statistically significant increase in number of inappropriate orders (p=0.005) and amount of albumin (p<0.001) used in the diagnosis and treatment of HRS. Conclusion: The implementation of a CDS order set without a companion education program decreased inappropriate albumin use for large volume paracentesis and treatment of SBP, however, the inappropriate use of albumin for management of HRS increased. Though the order set had a modest impact, we conclude that institutions should also initiate educational and targeted physician interventions to increase compliance with guidelines and decrease inappropriate albumin use and associated costs.