Institutional Cost Savings Research Articles

Haemorrhoid artery ligation - recto anal repair (HAL-RAR) blind versus Doppler: a systematic review and meta-analysis.

Haemorrhoids remain a highly prevalent condition in Australia, affecting 39% of the adult Australian population. While haemorrhoidectomy remains the gold standard in the management of haemorrhoids, newer techniques such as haemorrhoid artery ligation-recto anal repair (HAL-RAR) are emerging as promising management modalities. We compare the efficacy of non-Doppler guided (non-DG) HAL-RAR versus Doppler-guided (DG) HAL-RAR in the management of haemorrhoids. This study was registered with PROSPERO (CRD42022353806) and adhered to PRISMA 2020 guidelines. We conducted a systematic review using Medline, Embase and Cochrane database for comparative studies between Doppler-guided HAL-RAR and non-Doppler-guided HAL-RAR in accordance with the PRISMA 2020 statement for reporting systematic reviews. Five studies were included in our systematic review and meta-analysis. There was no clinically significant difference in operative times (SMD 0.46, 9% CI -3.16 0 4.08, P = 0.804) or post-operative bleeding (P = 0.142) between the two groups. DG HAL-RAR patients were more likely to have post-operative urinary retention (P < 0.001). Non-DG patients were less likely to experience recurrence (OR 5.12, P < 0.001). Our review of non-DG HAL-RAR compared to DG HAL-RAR reflects the non-inferiority of the non-DG HALRAR procedure. We hope that these results would provide a guide to clinicians performing HAL-RAR, and would provide some cost savings for institutions who are unable to procure the necessary equipment for DG HAL-RAR.

Incidence of Post-ERCP Pancreatitis in Patients Receiving Rectal Indomethacin vs. Compounded Rectal Diclofenac Prophylaxis.

Endoscopic retrograde cholangiopancreatography (ERCP) carries a 3-15% risk of post-ERCP pancreatitis (PEP). Rectal indomethacin reduces the risk of PEP, but its cost has increased more than 20-fold over the past decade. Rectal diclofenac is also used to prevent PEP but is not commercially available in the United States. The aim of this study is to compare the incidence of PEP after administration of commercially available rectal indomethacin versus compounded rectal diclofenac and assess financial implications. ERCP cases at our institution with administration of 100mg rectal indomethacin or 100mg compounded rectal diclofenac between May 2018 and January 2022 were retrospectively reviewed. The incidence and severity of PEP was compared between the indomethacin (n = 728) and diclofenac (n = 304) groups. Risk factors (young age, female sex, history of pancreatitis or PEP, sphincterotomy during procedure, pancreatic indication, trainee involvement) and protective factors (prior sphincterotomy, pancreatic duct stenting) for PEP were compared between groups. 60 patients (8.2%) in the rectal indomethacin group and 25 patients (8.2%) in the compounded rectal diclofenac group developed PEP, resulting in moderate or severe PEP in 9 (15.0%) and 2 (8.0%) patients, respectively. The compounded rectal diclofenac group had more trainee involvement (46.1% vs. 32.8%, p = 0.0001) and more prior sphincterotomy cases (15.8% vs. 10.6%, p = 0.0193) compared to the rectal indomethacin group; no statistically significant differences were observed in all other risk and protective factors. Following switch to compounded rectal diclofenac, institutional annual cost savings amounted to $441,460.62 and patient charge decreased 45-fold. This retrospective single-center real-world analysis showed similar efficacy of rectal indomethacin and compounded rectal diclofenac in preventing PEP but demonstrates substantial cost savings after switching to compounded rectal diclofenac.

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

I-125 eye-plaque seed economics: To re-use or to not re-use? A single institutional cost savings analysis of re-using I-125 radioactive seeds for eye—Plaque brachytherapy

INTRODUCTIONIodine-125 (I-125) seeds, commonly used in low-dose rate brachytherapy for ocular malignancies, are often discarded after a single use. This study examines the potential cost savings at an institution with high ocular melanoma referrals, by re-using I-125 seeds for eye-plaque brachytherapy. METHODSIn this single-institutional retrospective analysis, data was collected from I-125 seed orders from 8/2019 through 10/2022. Information including number of seeds ordered per lot, number of plaques built per lot, and number of seeds used per lot were collected. Cost per lot of seed was assumed to be the current cost from the most recent lot of 35 seeds. RESULTSDuring the study, 72 I-125 seed lots were ordered bi-weekly, with a median of 35 seeds per lot (Range: 15–35). Each seed was used on average 2.26 times prior to being discarded. The average duration of each seed lot used was 62.2 days (Range: 21–126). Each seed lot contributed to the construction of an average of 8.4 eye plaques (Range: 2–20). With seed recycling, 2,475 seeds were used to construct 608 eye-plaques. Without re-using practice this would require 5,694 seeds. This resulted in a percentage cost savings of 56.5%, with a total seed cost reduction of $344,884, or $559 per eye-plaque on average. CONCLUSIONThis is the first study to evaluate cost savings relative to re-using I-125 seeds for eye plaques. The data demonstrates how an institution can decrease costs associated with I-125 radiation seeds used for eye-plaque brachytherapy by re-using them.

Vascular Closure Devices versus Manual Compression in Cardiac Interventional Procedures: Systematic Review and Meta-Analysis.

Backgrounds Manual compression (MC) and vascular closure device (VCD) are two methods of vascular access site hemostasis after cardiac interventional procedures. However, there is still controversial over the use of them and a lack of comprehensive and systematic meta-analysis on this issue. Methods Original articles comparing VCD and MC in cardiac interventional procedures were searched in PubMed, EMbase, Cochrane Library, and Web of Science through April 2022. Efficacy, safety, patient satisfaction, and other parameters were assessed between two groups. Heterogeneity among studies was evaluated by I2 index and the Cochran Q test, respectively. Publication bias was assessed using the funnel plot and Egger's test. Results A total of 32 studies were included after screening with inclusion and exclusion criteria (33481 patients). This meta-analysis found that VCD resulted in shorter time to hemostasis, ambulation, and discharge (p < 0.00001). In terms of vascular complication risks, VCD group might be associated with a lower risk of major complications (p = 0.0001), but the analysis limited to randomized controlled trials did not support this result (p = 0.68). There was no significant difference in total complication rates (p = 0.08) and bleeding-related complication rates (p = 0.05) between the two groups. Patient satisfaction was higher in VCD group (p = 0.002). Meta-regression analysis revealed no specific covariate as an influencing factor for above results (p > 0.05). Conclusions Compared with MC, the use of VCDs significantly shortens the time of hemostasis and allows earlier ambulation and discharge, meanwhile without increase in vascular complications. In addition, use of VCDs achieves higher patient satisfaction and leads cost savings for patients and institutions.

Healthcare system conversion to a biosimilar: Trials and tribulations.

While biologic medications have transformed the care and management of millions of patients, they are a large financial strain on the healthcare system. Biosimilar medications present a great opportunity to improve care affordability. However, despite streamlined approval processes and the potential for cost savings, the acceptance and adoption of biosimilars have been slow. This descriptive report illustrates the preparation for, challenges of, and execution of an enterprise-wide biosimilar conversion within a large healthcare system. The 3 phases of biosimilar conversion utilized at our institution included selection of a biosimilar, pharmacy and therapeutics (P&T) committee approval, and implementation. When selecting a biosimilar, clinical data, medication safety, cost, institutional cost savings, payer coverage, patient assistance programs, and additional patient services should be taken into consideration to ensure patient care is not affected. Understanding and endorsement of biosimilar use by physician leadership, care managers, and pharmacists are crucial before implementation. P&T committee approval with clear delineation of the patient population (naive vs experienced), disease states, and whether the biosimilar would be the preferred medication should be obtained. Transparent communication of clear expectations to patients and coordination with the information technology (IT), contracting, and supply chain departments are necessary before the go-live date. Contracting and IT implementations should ideally take potential changes in biosimilar adoption into consideration and have enough flexibility to account for these changes. Planned evaluations of patients' experiences with the change to the biosimilar should be incorporated as part of the implementation plan. The barriers to biosimilar adoption are plentiful. Careful planning, clear communication, and coordination with all affected disciplines can ensure successful biosimilar conversion.

Universal quantitative neuromuscular blockade monitoring at an academic medical center—A multimodal analysis of the potential impact on clinical outcomes and total cost of care

BackgroundQuantitative train-of-four monitoring is not currently the standard of care when using neuromuscular blockade, although it has the potential to eliminate the complications of residual neuromuscular blockade. There are major costs associated with the complications of residual neuromuscular blockade as well as the purchase of quantitative train-of-four monitors. The aim of this study was to determine the cost effectiveness of universal quantitative train-of-four ratio monitoring as it pertains to purchase and use of quantitative train-of-four monitors in comparison with potential costs of managing possible complications of residual neuromuscular blockade such as reintubation and pneumonia. MethodsThis observational study was conducted by the anesthesiology service for an urban academic medical center. All patients included were undergoing general endotracheal anesthesia with the use of neuromuscular blocking agents who were extubated at the end of their procedure. Qualitative and quantitative train-of-four ratio monitoring prior to extubation were compared to estimate the local incidence of residual post-operative neuromuscular blockade. The hospital electronic medical record and financial database were used to estimate the number of patients at risk for post-operative pneumonia or re-intubation, as well as the marginal costs associated with these complications. The incidence of residual post-operative neuromuscular blockade at the time of extubation was determined. The variable costs of care for patients who did or did not suffer either pneumonia or re-intubation in the postoperative period was compared to the annual cost of universal quantitative train-of-four ratio monitoring. ResultsA sensitivity analysis demonstrated that universal quantitative train-of-four ratio monitoring would result in a net cost savings for a broad range of efficacy estimates with regard to the reduction of post-operative pulmonary complications. ConclusionsIntroduction of universal quantitative train-of-four ratio monitoring may be justified based solely on the potential institutional cost savings.

Cost Savings From a Policy to Diagnose and Prevent Transmission of Adenoviral Conjunctivitis in Employees of a Large Academic Medical Center

Adenoviral conjunctivitis is highly contagious, can be associated with systemic infections, and can cause chronic visual impairment. It accounts for a large proportion of acute conjunctivitis. Outbreaks of epidemic keratoconjunctivitis (EKC) are costly in terms of productivity loss from work furloughs and spread to patients and have resulted in clinic and departmental closures. To examine the institutional cost savings of a policy to diagnose adenoviral conjunctivitis and triage and furlough medical center employees with this condition to prevent outbreaks. This quality improvement study assessed Johns Hopkins Medicine employees with red eye from November 1, 2011, through October 31, 2018, who were triaged at the occupational health clinic whose conditions were diagnosed using polymerase chain reaction (PCR) validated for adenoviral conjunctivitis. Only employees with positive PCR test results were furloughed, with furlough length tailored to subtype (a minimum of 2 weeks for EKC and 1 week otherwise). Total number of furloughs avoided and cost savings associated with reducing unnecessary furloughs. Of 2142 employees with red eye, 1520 (71.0%) underwent PCR testing; 130 (8.6%) had positive adenoviral PCR test results, of whom 41 (31.5%) had EKC. Furloughing 130 employees with positive PCR test results vs furloughing all 1520 employees clinically suspected of having adenoviral conjunctivitis represented an estimated annual savings of $442 073, or $3 094 511 during 7 years. The cost of performing PCR on employees suspected of having adenoviral conjunctivitis was 5.0% of the cost associated with furloughing all employees with red eye. No outbreaks occurred. In this quality improvement study, this policy, notable for development and use of PCR for adenoviral conjunctivitis on a large scale, resulted in substantial cost savings from fewer work furloughs compared with the number of employees who would have been furloughed based on clinical diagnosis. These results may provide impetus for policy adoption by other institutions and for development of a rapid, sensitive, and specific diagnostic test for adenoviral conjunctivitis.

Spatiotemporal Integration of Mobile, Satellite, and Public Geospatial Data for Enhanced Credit Scoring

Credit scoring of financially excluded persons is challenging for financial institutions because of a lack of financial data and long physical distances, which hamper data collection. The remote collection of alternative data has the potential to overcome these challenges, enabling credit access for such individuals. Whereas alternative data sources such as mobile phones have been investigated by previous researchers, this research proposes the integration of mobile-phone, satellite, and public geospatial data to improve credit evaluations where financial data are lacking. An approach to integrating these disparate data sources involving both spatial and temporal analysis methods such as spatial aggregation was employed, resulting in various data combinations. The resulting data sets were used to train classifiers of varying complexity, from logistic regression to ensemble learning. Comparisons were based on various performance metrics, including accuracy and the area under the receiver operating-characteristic curve. The combination of all three data sources performed significantly better than mobile-phone data, with the mean classifier accuracy and F1 score improving by 18% and 0.149, respectively. It is shown how these improvements can translate to cost savings for financial institutions through a reduction in misclassification errors. Alternative data combined in this manner could enhance credit provision to financially excluded persons while managing associated risks, leading to greater financial inclusion.

624. Significant Institutional Cost Savings from OPAT-Facilitated Discharge for Patients with Challenging Situations

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) programs are becoming a standard of care, however, program cost justification remains a challenge. One area of focus for institutions is facilitating timely discharge from the inpatient setting, and difficult to discharge patients are a group with which OPAT teams can be particularly impactful.MethodsThis retrospective review identified patients intervened upon by the Nebraska Medicine OPAT team during the initial nine months after program implementation (4/1/19 - 12/31/19) for which routine efforts at discharge by primary teams had failed. Patients were planned for extended inpatient stays to complete the full duration of parenteral antibiotic therapy due to discharge issues given the therapy plan initially recommended by infectious disease consult teams. Outcomes evaluated included inpatient days of therapy avoided, associated financial metrics, and 30-day readmission rates. A matched cohort of patients with similar lengths-of-stay, infectious disease indications, medication use, and lack of major complications was identified to calculate a cost per inpatient day avoided.ResultsA total of 17 difficult to discharge patients were intervened on by the OPAT team, leading to avoidance of 429 planned inpatient days. Based on calculation from internal matched cohort data, these OPAT interventions avoided an estimated $943,000 in total inpatient costs. All-cause 30-day readmission was 24% (4 of 17 patients). Additionally, 15 of these therapy courses were shifted to hospital-associated outpatient infusion centers. Facilitation of enrollment for 11 of these patients in pharmaceutical manufacturer patient assistance programs resulted in replacement of outpatient medication totaling over $28,000 in value. Reimbursements for two additional patients through either governmental or private insurance generated over $11,000 in margin for the health system.ConclusionAttention to complex discharge facilitation by OPAT programs can be a significant contribution to program cost justification, while also transitioning patients to therapy plans that lead to similar clinical outcomes when compared to the overall OPAT population.Disclosures All Authors: No reported disclosures

Exploring Cost Savings with Specialty Biologic Drugs Administered to Adult Inpatients with Inflammatory Bowel Disease.

Background: Specialty infusion and self-injectable biologic drugs for the treatment of inflammatory bowel disease (IBD) are high-cost medications. When administered to hospital-admitted patients, these medications are not reimbursed on an individual basis but rolled into a per diem payment by most payers in the United States (US). Therefore, choosing to administer these medications in the inpatient setting may reveal negative financial implications for some health care institutions. Selecting an alternative site of care to administer these medications during the clinical management process may lead to cost savings. Objective: Review the clinical necessity of inpatient specialty biologic administrations for the treatment of IBD to identify and quantify potential cost saving opportunities. Methods: Using patient medical records at a US academic medical center, we retrospectively identified inpatient administrations of specialty infusion and self-injectable biologic medications for IBD treatment from June 1, 2016 to May 31, 2017. Guided by a standardized form, an evaluation team consisting of 3 of the investigators determined the clinical necessity of each specialty biologic medication administration within the inpatient setting. Costs and reimbursement rates for administration in both the inpatient and outpatient settings were procured and tabulated. Results: Seventeen inpatient specialty biologic administrations for IBD during the 12 month study period were identified. Of these, 11 administrations were given for the treatment of Crohn's disease (CD) and 6 for ulcerative colitis (UC). The evaluation team determined that 65% of these administrations were clinically necessary as inpatient administrations, and that 35% were not. The sum of the wholesale acquisition costs (WAC) for clinically necessary inpatient biologic administrations totaled $54 737, and the WAC for those administrations deemed not clinically necessary totaled $43 702. Further analysis of administration events revealed that the institution could have realized an estimated $13 817 in additional revenue above the cost of the drug if eligible inpatient biologic administrations had been received in the institution's outpatient clinic setting instead. Conclusion: Administering specialty biologic drugs for the treatment of IBD in the care setting best aligned with existing reimbursement structures may lead to institutional cost savings.

Clinical and economic effects of an antimicrobial stewardship intervention in a surgical intensive care unit.

To study the effects of an Antimicrobial Stewardship (AMS) programme designed as a once-weekly "Prospective Audit with Feedback and Intervention" in a surgical intensive care unit. Retrospective, pre-/post-observational comparison of antimicrobial drug use, patient safety, and cost of care. During the 12-month AMS period the consumption of antimicrobials dropped by 18.3%. While the consumption of broad-spectrum antibiotics decreased by 17.4% the consumption of narrow spectrum penicillins increased by 89.9%, reaching 26.3% of the total antibiotic consumption. Treatment outcomes and rates of Clostridioides difficile infections before and during the programme were not significantly different. The reduction in antimicrobial costs of 46,393€ was offset by an expenditure of 8,047€, for both human resources and additional radiological procedures, resulting in a net saving of 38,346€. 92% of the antibiotic related savings were due to the reduced use of tigecycline and linezolid, and decreases in drug retail prices. AMS programmes can both reduce the consumption of antimicrobials and modify their spectrum in intensive care without negatively affecting treatment outcomes. The resulting cost savings are negligible. The incentive to implement such programmes cannot, therefore, be immediate institutional cost savings, but should be rather the long-term goal of reducing antibiotic resistance, and its consequences, in terms of long-term health care costs.

Process and Clinical Outcomes of a Biosimilar Adoption Program with Infliximab-Dyyb.

In 2016, the FDA approved infliximab-dyyb (IFX-dyyb) as a biosimilar to infliximab (IFX). Deemed to have comparable efficacy and safety to IFX, IFX-dyyb is 20%-30% less expensive, allowing significant cost savings for institutions and some payers. In 2018, IFX was reported to be the drug with the highest spend since 2013, costing $3.8 billion; however, transition to IFX-dyyb would save $1.1 billion. Regardless, many institutions have not transitioned to IFX-dyyb or other IFX biosimilars (e.g., IFX-abda) because of concerns about clinical outcomes, uncertainty regarding financial impact, and barriers to operationalizing biosimilar adoption. At Boston Medical Center, a decision was made in March 2018 to adopt IFX-dyyb and transition patients who have been on IFX for ≥ 6 months for all indications to IFX-dyyb. To (a) describe a biosimilar adoption process of IFX-dyyb in patients on IFX for ≥ 6 months; (b) characterize cost savings of transitioning patients to IFX-dyyb; and (c) evaluate real-world clinical outcomes of adult patients with inflammatory bowel disease (IBD) who transitioned to IFX-dyyb. This is a retrospective cohort study of patients eligible for the IFX-dyyb switch from March 2018 to June 2019 at a large academic medical center. For process outcomes, we collected the proportion of patients who transitioned to IFX-dyyb and calculated the cost savings generated. To assess clinical outcomes of adult IBD patients who transitioned, we collected IFX and IFX-dyyb dosage, Harvey Bradshaw Index (HBI) or Simple Clinical Colitis Activity Index (SCCAI) scores, c-reactive protein (CRP) levels, and colonoscopy results. Descriptive statistics, Wilcoxon signed-rank test, and McNemar's test were used for statistical analyses. Of 151 eligible patients, 146 (97%) successfully transitioned to IFX-dyyb. Based on our conversion rate to IFX-dyyb, our health system is forecasted to save approximately $500,000 annually. From March to June 2018, 63 of 75 (84%) eligible IBD patients transitioned from IFX to IFX-dyyb. In this cohort, of the 40 patients with HBI or SCCAI scores before and after transition, 36 (90%) maintained remission. For 32 patients, the mean CRP (SD) before transition was 11.2 (22) and 4.1 (4.8) after transition (P = 0.09). Since the IFX-dyyb transition, 9 patients had a colonoscopy, of which 5 (56%) were in endoscopic remission. As of October 2018, 56 (89%) patients continued with IFX-dyyb after transition. Of the 46 patients who had 12-15 months posttransition data, 38 (83%) remained on IFX-dyyb. Implementation of a biosimilar adoption program can be successful and result in significant cost savings without compromising clinical outcomes. A model that uses actionable strategies and embraces collaboration among stakeholders is described here, with outcomes demonstrating successful IFX-dyyb uptake and no changes in clinical outcomes of transitioned adult patients with IBD. No outside funding supported this study. Farraye reports advisory board fees from Janssen, Merck, and Pfizer. Shah reports speaker fees from Pfizer. The other authors have nothing to disclose.

Economic benefits of pharmacy technicians practicing at advanced scope: A systematic review.

To critically appraise the literature to determine the cost and time savings for institutions when pharmacy technicians practice in advanced scope roles. A systematic review was registered with Prospero and conducted in January 2019. Searches were conducted in Business Source Pro, CINAHL, EconLit, EMBASE, InformGlobal, Medline, ProQuest, PubMed, Scopus and Web of Science. Search terms included pharmacy technician/pharmacy assistant and cost or time or economic evaluation. After article selection in the web-based platform Covidence©, data was extracted, and a narrative review was performed. A total of 16 publications were eligible for inclusion in the review. Pharmacy technicians practicing at advanced scope led to both cost savings and time savings. Six studies reported a cost saving, six reported a time saving and four reported both time and cost savings. Annual savings ranged from AUD $4526 - $88,719.89, linked primarily to the difference in wages between pharmacists and pharmacy technicians. Studies that focused on time savings evaluated checking dispensed items, taking medication histories and entering chemotherapy orders; demonstrating savings of up to 5min per task completed. Appropriately trained pharmacy technicians practicing at advanced scope have the potential to save time and reduce hospital costs. Identifying the cost saving opportunities from technicians acting in advance scope roles will provide incentives for hospitals to expand their technician workforce.

Enhanced recovery after surgery (ERAS) protocols in neonates should focus on the respiratory tract.

Enhanced recovery after surgery (ERAS) protocols have shown significant benefits in terms of patient outcomes and institutional cost savings in colorectal and bariatric surgery. This has not, however, been tried in the neonatal setting. One of the major barriers to developing ERAS protocols in the neonatal intensive care unit (NICU) is the often-prolonged intubation of neonates after surgery. To this end, we evaluated our institutional data to determine if prolonged intubation post-operatively is associated with adverse events. This is a retrospective cohort study of neonates who were intubated for a surgical procedure from January 2012 to December 2016. Documented data included pre-operative intubation status, timing of post-operative extubation: immediate (< 24h) or delayed (> 24h), and adverse respiratory events. The Fisher exact test and Student's t test were used to study differences amongst categorical and continuous variables, respectively. 58 surgical procedures were identified, where the patient was intubated specifically for the surgical intervention, of which 28 were extubated immediately and 30 were extubated in a delayed fashion. The overall incidence of adverse respiratory events was increased in the delayed extubation group (P = 0.03). Healthcare providers should encourage early extubation after neonatal surgery. Consideration should be given to implementing ERAS protocols in NICUs. Prognosis study-level II.

Office-Based Spirometry: A New Model of Care in Preoperative Assessment for Low-Risk Lung Resections

Formal pulmonary function testing with laboratory spirometry (LS) is the standard of care for risk stratification before lung resection. LS and handheld office spirometry (OS) are clinically comparable for forced expiratory volume in 1 second and forced vital capacity. We investigated the safety of preoperative risk stratification based solely on OS. Patients at low-risk for cardiopulmonary complications were enrolled in a single-center prospective study and underwent preoperative OS. Formal LS was not performed when forced expiratory volume in 1 second was more than 60% by OS. Propensity score matching was used to compare patients in the OS group to low-risk institutional database patients (2008 to 2015) who underwent LS and lung resection. Standardized mean differences determined model covariate balance. The McNemar test and log-rank test were performed, respectively, for categorical and continuous paired outcome data. There were 66 prospectively enrolled patients who received OS and underwent pulmonary resection, and 1,290 patients received preoperative LS, resulting in 52 propensity score-matched pairs (83%). There were no deaths and two 30-day readmissions per group. The major morbidity risk was similar in each group (7.7%). All analyses of discordant pair morbidity had p exceeding 0.56. There was no association between length of stay and exposure to OS vs LS (p= 0.31). The estimated annual institutional cost savings from performing OS only and avoiding LS was $38,000. Low-risk patients undergoing lung resection can be adequately and safely assessed using OS without formal LS, with significant cost savings. With upcoming bundled care reimbursement paradigms, such safe and effective strategies are likely to be more widely used.

Efficacy of Liposomal Bupivacaine Infiltration on the Management of Total Knee Arthroplasty

ImportanceLiposomal bupivacaine is a novel extended-duration anesthetic that has recently been used for local infiltration in total knee arthroplasty (TKA). Athough liposomal bupivacaine is widely used, it is unknown if the benefits justify the cost in the veteran population at our institution.ObjectiveTo evaluate a change in practice: the effect of local infiltration of liposomal bupivacaine on perioperative outcomes in patients undergoing primary TKA.Design, Setting, and ParticipantsA retrospective cohort study was conducted among patients who underwent primary TKA at a Veterans Affairs Medical Center before (March 3, 2013-March 2, 2014) and after (March 3, 2014-March 2, 2015) the implementation of liposomal bupivacaine for local infiltration in TKA. InterventionDrug utilization evaluation of liposomal bupivacaine for local infiltration in TKA.Main Outcomes and MeasuresUse of opioids after discharge from the postanesthesia care unit.ResultsAmong 199 patients, those who received liposomal bupivacaine after primary TKA (mean [SD] age, 65.3 [6.9] years; 93 males and 5 females) had a reduced median opioid use in the first 24 hours after surgery compared with those who did not receive liposomal bupivacaine (mean [SD] age, 64.9 [8.4] years; 95 males and 6 females; [intravenous morphine equivalents, 12.50 vs 22.50 mg; P = .001]). The use of patient-controlled analgesia was also reduced among patients who received liposomal bupivacaine vs those who did not (49 vs 91; P < .001). A reduction in the use of antiemetics was observed in the first 24 hours after surgery (13 vs 34; P = .001) and in the postanesthesia care unit among those who received liposomal bupivacaine vs those who did not (4 vs 20; P = .001). The number of patients in the postanesthesia care unit with no pain was improved among those who received liposomal bupivacaine vs those who did not (44 vs 19; P < .001). Although median (interquartile range) pain scores in the postanesthesia care unit were improved among patients who received liposomal bupivacaine vs those who did not (4.0 [0.0-6.6] vs 5.5 [3.0-7.5]; P = .001), patients who received liposomal bupivacaine had greater median (interquartile range) pain scores 48 hours (5.5 [4.0-7.0] vs 5.0 [3.0-6.0]; P = .01), 72 hours (5.0 [4.0-6.0] vs 4.0 [2.0-6.0]; P = .002), and 96 hours (5.0 [3.0-6.5] vs 4.0 [1.0-5.0]; P = .003) after surgery than those who did not receive liposomal bupivacaine. There was no difference in the median length of stay between the 2 groups. Institutional cost savings was estimated at $27 000 per year.Conclusions and RelevanceLocal infiltration of liposomal bupivacaine reduces use of opioids in the first 24 hours after primary TKA. Similarly, reduction in antiemetic use and improved postoperative pain are also seen in the first 24 hours after surgery but are limited to this time frame. Furthermore, a positive institutional cost savings was observed.

Clinical and Cost Comparison Evaluation of Inpatient Versus Outpatient Administration of EPOCH-Containing Regimens in Non-Hodgkin Lymphoma

Background: Etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (EPOCH)-containing regimens are frequently utilized in non-Hodgkin’s lymphoma, however, the incidence of febrile neutropenia (FN) in patients receiving inpatient versus outpatient EPOCH has not been described. Additionally, no comparisons have been made regarding financial implications of EPOCH administration in either setting. This study’s primary objective was to compare hospital admissions for FN in patients receiving inpatient or outpatient EPOCH. Methods: A single-center, institutional review board-approved review was conducted for adults receiving EPOCH beginning January 2010. Clinical and financial data were collected through chart review and the institution’s financial department. Descriptive statistics were utilized for analysis. Results: A total of 25 patients received 86 cycles of an EPOCH-containing regimen (61 [70.9%] inpatient). Five (8.2%) inpatient cycles resulted in an admission for FN compared to 4 (16%) outpatient cycles. Prophylactic antifungal and antiviral agents were prescribed more often after inpatient cycles (>80%) compared to outpatient cycles (<50%). Overall, 27 (31.4%) of 86 cycles did not receive granulocyte colony-stimulating factor support. Outpatient EPOCH administration was associated with a cost savings of approximately US$141 116 for both chemotherapy costs and hospital day avoidance. Conclusion: EPOCH-containing regimens can be safely administered in the outpatient setting, which may result in cost savings for healthcare institutions.

Implementation of national practice guidelines to reduce waste and optimize patient value

BackgroundThe financial health care crisis has provided the platform to drive operational improvements at US health care facilities. This has led to adoption of lean operation principles by many health care organizations as a means of eliminating waste and improving operational efficiencies and overall value to patients. We believe that standardized implementation of national practice guidelines can provide the framework to help to reduce financial waste. Materials and methodsWe analyzed our institutional preoperative electrocardiogram (ECG) ordering practices for patients undergoing elective surgery at our institution from February–March, 2012 to identify utilization and review compliance with American Heart Association guidelines. We then implemented an ECG ordering algorithm based on these guidelines and studied changes in ordering patterns, associated cost savings and hospital billing for the same period in 2013. ResultsFrom February–March 2012, 677 noncardiac surgical procedures were performed at our institution, and 312 (46.1%) had a preoperative ECG. After implementation of our evidence-based ECG ordering algorithm for the same period in 2013, 707 noncardiac surgical cases were performed, and 120 (16.9%) had a preoperative ECG. Preoperative ECG utilization dropped 63% with an annual institutional cost savings of $72,906 and $291,618 in total annual health care savings. Based on our data, US-wide implementation of our evidence-based ECG ordering algorithm could save the US health care system >$1,868,800,000 per year. ConclusionsHere, we demonstrate that standardized application of a national practice guideline can be used to eliminate nearly $2 billion per year in waste from the US health care system.

Impact of an innovative blood factor stewardship program on drug expense and patient care.

An innovative pharmacist-led program to improve prescribing, dosing, and monitoring of clotting factor therapy within a large health system is described. In an initiative to optimize patient outcomes and control costs associated with the use of clotting factor concentrates, the pharmacy department at University of North Carolina Medical Center (UNCMC) led the development of a "factor stewardship program" in collaboration with UNCMC hematologists. Key steps in program development and implementation included (1) selection of one formulary product within each clotting factor class, (2) establishment of guidelines on blood factor prescribing, order review, compounding, and administration, and (3) initial and ongoing education of pharmacy, nursing, and medical staff. As part of the program, a designated pharmacist rounds with hematologists daily, recommending treatment plan modifications and dosage adjustments as appropriate. Now in its fifth year, the stewardship program has enabled consistent pharmacist oversight of all aspects of clotting factor use and enhanced transitions-of-care coordination. Through optimization of product selection, dosing regimens, and infusion frequencies, the number of blood factor doses in fiscal year 2013 was reduced by 45% from the prior year despite a 22% increase in the volume of treated patients; in patients with hemophilia A, re-admissions due to bleeding episodes have declined. During the four-year period ending in July 2014, estimated cost savings attributable to the stewardship program exceeded $4 million annually. Implementation of the UNCMC stewardship program has led to improved outcomes in patients receiving clotting factor concentrates, with significant institutional cost savings.