Potential Cost Avoidance Research Articles

Characterizing and developing strategies for the treatment of community-acquired pneumonia at a community hospital.

Patients admitted to Lions Gate Hospital, North Vancouver, British Columbia, with a primary diagnosis of community-acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared with 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential savings of 406 bed days and warranted an investigation into the management of CAP. To characterize and provide recommendations for the management of CAP. A retrospective chart review of patients admitted with a primary diagnosis of CAP between May 1, 2000 and August 31, 2000. Fifty-one patients were included in the study, with a mean LOS of 9.9 days and a median LOS of five days. Based on pneumonia severity index scores calculated for each patient, eight patients (16%) were admitted inappropriately. Initial empirical antibiotic choices were consistent with the Canadian CAP guidelines in 27 patients (53%), with inconsistencies arising mainly because cephalosporin or azithromycin monotherapy regimens were prescribed. Step-down from intravenous to oral antibiotics occurred in approximately 20 patients (39%). An additional 12 patients (24%) could have undergone step-down, and step-down was not applicable in 19 patients (37%). The potential annual cost avoidance from implementing admission criteria based on a pneumonia severity index score, applying step-down criteria and promoting early discharge criteria was estimated to be $220,000. Considerable variability exists in the treatment of CAP. A CAP preprinted order sheet was developed to address the issues identified in the present study and provide consistency in the management of CAP at Lions Gate Hospital.

PDB12: A PHARMACOECONOMIC ANALYSIS OF WEIGHT-REDUCTION THERAPY IN A HYPOTHETICAL COHORT OF OBESE CHINESE PATIENTS WITH IMPAIRED GLUCOSE TOLERANCE

OBJECTIVES: To conduct a pharmacoeconomic analysis to estimate the potential cost avoidance due to reduced rate of incidence of diabetes after weight-reduction therapy in obese Chinese patients with impaired glucose tolerance (IGT). METHODS: The incidence of IGT-to-diabetes mellitus (DM) conversion of two hypothetical cohorts of obese Chinese patients with IGT, either managed with diet control (n = 100) or diet control plus orlistat (n = 100), were projected over a two-year period. The probabilities of IGT-to-DM progression in the orlistat plus diet group and the diet only group were estimated from a published study in a non-Chinese and a westernized Chinese population, respectively. Direct medical costs of management of type 2 diabetes were estimated from a public budget perspective. RESULTS: The estimated rates of IGT-to-DM conversion were 1.9% for the orlistat plus diet group and 8% for the diet only group. The total costs of DM management at the end of the first and second years were estimated to be HK$8,187 and HK$23,390 ($HK 7.8 = $US 1) for the orlistat group. In the diet only group, the costs of DM management were HK$34,469 in year one and HK$100,123 in year two. The cost avoidance associated with orlistat therapy were calculated to be HK$26,282 and HK$75,092 per 100 patients at the end of the first and second years, respectively. CONCLUSIONS: Results of the present study suggest positive economic impacts of weight-reduction therapy in a hypothetical Chinese population with IGT in the prevention of type 2 diabetes.

Reengineering Respiratory Support Following Extubation: Avoidance of Critical Care Unit Costs

We prospectively investigated alternative clinical practice strategies for critically ill trauma patients following extubation to evaluate the cost-effectiveness of these maneuvers. The primary change was elimination of the routine use of postextubation supplemental oxygen, with concurrent utilization of noninvasive positive pressure ventilatory support (NPPV) to manage occurrences of postextubation hypoxemia. Prospective, consecutive accrual of patients undergoing extubation. Trauma ICU in a university hospital. All patients received mechanical ventilation using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode. The patients were extubated to room air following a 20-min preextubation trial of 5 cm H(2)O CPAP at FIO(2) of 0.21, and demonstrating a spontaneous respiratory rate </= 38 breaths/min, pH >/= 7.30, PaCO(2) </= 50 mm Hg, and PaO(2) >/= 50 mm Hg. The subgroup of patients who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of extubation were treated with NPPV for up to 48 h duration. Patients who failed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room air. Seventy-two patients (13%) became hypoxemic within 24 h, and NPPV was administered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, and received mechanical ventilation for a mean of 4 days. Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overall reintubation rate for the group (n = 536) was 6.2%; for the postextubation hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The elimination of routine supplemental oxygen via nasal cannula following extubation resulted in a potential direct cost avoidance of $50,006.88 for 451 patient days. Moreover, the 52 patients who were spared reintubation and mechanical ventilation provided an additional potential cost avoidance of $19,740.24 in unused ventilator days per patient. Eliminating the routine use of supplemental oxygen and employing NPPV as a method to prevent reintubation can facilitate a more aggressive, cost-effective strategy for the management of the trauma ICU patient who has been extubated.

PIC9 The Economic Impact of A Drug Information Service

OBJECTIVE: A cost-avoidance model was developed to determine potential cost savings (PCS) of a drug information service (DIS) that results from answering a drug information request. DESIGN: Patient-specific questions received by the drug information service were reviewed and evaluated. A panel determined whether or not appropriate drug therapy would have been employed if the DIS had not been consulted. Potential outcomes of drug information requests were classified using a decision-tree model. A severity rating with potential cost avoidance was then attached to each applicable request to predict PCS of the DIS. RESULTS: Seventy-seven of the 570 drug information responses in the six-week study period had assessable PCS to the institution. During the study interval, PCS were estimated to be $196,000. Projected to one year, PCS reached $1.7 million. Of the savings noted, most were in the categories of increased monitoring and additional treatment. Annual PCS using a sensitivity analysis ranged from $423,601 to $1,922,560 per year. CONCLUSIONS: This model demonstrates that the DIS at our institution does provide substantial cost avoidance. This model may be modified to evaluate PCS in other areas of pharmacy practice.

Cost savings and avoidance from clinical interventions.

A method that lets a pharmacy department collect data on cost savings and avoidance achieved through pharmacist interventions is described. The pharmacist intervention program at an 849-bed institution is based on the pharmacist's evaluation of the patient, the disease or condition, and the appropriateness of the drug therapy selected. The pharmacist records the recommendation, the rationale, and the intervention outcome, and the data are entered into the medication order-entry system. An assigned code indicates the potential severity of consequences had the intervention not been made. The information is forwarded to the clinical interventions and financial assessment committee (CLIFAC) for analysis of cost savings and potential cost avoidance. To calculate savings, CLIFAC determines the drug acquisition and relevant laboratory costs that would have been charged, as well as the cost of a change in therapy. A method was developed that allows CLIFAC to use hospital-specific diagnosis-related-group data to determine potential cost avoidance as a function of hospital days prevented. From July 1994 through April 1995, 4648 interventions were documented by the 50-member inpatient and ambulatory care pharmacist staff and evaluated and quantified. Of these interventions, 87% were accepted by the medical staff. The accepted interventions represent a net therapy cost saving of $487,833, as well as a cost avoidance of $158,563 achieved by prevention of a potential net 371.9 additional hospital days. A pharmacy department's financial assessment committee evaluated pharmacist interventions by determining changes in the cost of therapy and estimating potential changes in the length of stay.

Re-engineering Tube Feeding Ordering, Delivery, And Administration In A 690-bed Tertiary Care Facility

LEARNING OUTCOME: To demonstrate the cost-effectiveness of an RD's intervention in leading an interdisciplinary quality team toward process improvement in tube feeding ordering, delivery, and administration.An opportunity was identified by clinical nutrition services to improve the process of tube feeding (TF) within the medical treatment facility. Findings suggested a large number of patients received less than 75% of total ordered volume of formula after 72 hours of infusion, some formulas were being diluted with free water, and numerous inconsistencies in ordering were identified. In addition, no universal procedure existed that delineated the role of the physician, nurse, or dietitian in TF administration. An interdisciplinary process improvement group was formed and led by the Director, Clinical Nutrition Services. The group met monthly for one year. A medical center instruction was developed to clearly delineate standards of practice and the roles and responsibilities of providers. Standardized adult and pediatric TF order forms were created to lessen the number of transcription errors in ordering, and to serve as an educational tool for our large number of house staff and residents. To limit the risk of cross contamination, decrease workload, and improve the hang-time of product, a closed-system of formula delivery was implemented. Previously identified problems with inappropriate site infusion and lack of tube flushing drove the change to use strictly Quantum® feeding pumps. Finally, an intensive education and training program was conducted on each nursing unit prior to implementing change. Benefits of this process improvement include actual annual cost savings of $55,000 in feeding bag supplies, $6,200 in nourishment worker man-hours, and $51,100 in nursing personnel expense. The potential cost-avoidance of clogged enteral tubes and replacement is roughly $43,350 monthly. Additionally, marked improvements were realized in the accuracy of TF ordering, attainment of nutritional goals, and level of satisfaction among medical staff. Registered dietitians can and should be pioneers of change in leading interdisciplinary groups to deliver cost-effective medical nutrition therapy.

Program for procurement of drugs for indigent patients

A program for procuring free medications for indigent patients from pharmaceutical manufacturers is described. A medical center that provides $36 million in free care annually to indigent patients sought a way to offset drug costs for these patients while maintaining the same level of care. The pharmaceuticals with the greatest impact on the pharmacy budget were identified; manufacturers of these pharmaceuticals were surveyed to determine if they offered free drugs to qualified patients. The net potential cost avoidance resulting from procuring these free drugs was estimated at $150,000 for the first year. A full-time pharmacist was hired to identify patients likely to qualify for such assistance, help patients apply for assistance, and coordinate the receipt and distribution of the resulting medication supplies. The program served 200 patients the first year (fiscal year 1992) and more than 300 patients the next year. Medications obtained for these patients included i.v. immune globulin, cancer chemotherapy agents, growth factors, antimicrobials, antiemetics, and interferons. The acquisition cost of the medications received was $448,851 in 1992 and $504,211 in 1993. A pharmacy-based program to procure free medications for indigent patients has helped to defray a medical center's expense of providing care.

Workload and cost-benefit of hospital pharmacy residents.

The workload performed by three hospital pharmacy residents during typical clinical rotations was quantified then subjected to cost-benefit analysis. Daily activities and interventions were recorded on standardized forms for a four-week period. The cost of a resident to provide direct patient care services was compared to that of a staff pharmacist. In addition, the balance of the residents' salary and partial salaries of any pharmacists spending time with the residents were included in the cost analysis. The interventions were analyzed for their impact on patient care and potential cost avoidance by an external review committee. Collectively, more than 660 hours were recorded. Fifty-two percent of hospital time was spent on education-related activities and 32 percent on the provision of clinical services. Thirty interventions were submitted to a review panel of three physicians. Of the 90 evaluations, 76 percent were considered to have a positive impact on patient care, 22 percent no effect, and two percent a potentially detrimental effect. In one case, reviewers thought that hospitalization could have been prolonged had the intervention not occurred. Cost-benefit analysis yielded a ratio of 1.4 to 1 in favour of the residents. While the major benefit of a residency program is the perceived long-term benefit to the profession and patients, this study suggests that even during their residency year, hospital pharmacy residents provide cost-beneficial clinical services.

Potential Cost-Avoidance with Oral Extended-Release Morphine Sulfate Tablets Versus Morphine Sulfate Solution

The costs of acquiring, preparing, and administering morphine sulfate extended-release tablets and morphine sulfate solution were compared. Pharmacists at an acute-care community hospital timed the pharmacy and nursing components of the process of preparing and administering single doses of morphine sulfate extended-release tablets 60 mg and morphine sulfate solution 5 mg/mL. The labor cost of each step was determined by multiplying the mean time required to perform the task by the median of the wage scale for the person performing it. Acquisition costs and ancillary supply costs were determined, and the overall cost of each therapy was calculated. The total time required for providing single doses did not differ substantially. However, assuming a total daily morphine sulfate dosage of 120 mg, the time required for administering extended-release morphine sulfate tablets 60 mg twice daily was determined to be 8.90 minutes, compared with 23.44 minutes for solution (4 mL of 5-mg/mL solution) six times daily. Thus, although the cost of acquiring extended-release tablets was considerably higher than that of solution, the total daily cost of therapy with tablets was less than half that of therapy with solution. The potential for cost avoidance and the clinical advantages associated with extended-release morphine sulfate tablets make this formulation an attractive therapeutic alternative.

Appropriateness of metronidazole use in a teaching hospital

The appropriateness of metronidazole use at a teaching hospital was determined by a retrospective audit. All orders for metronidazole received by the hospital pharmacy from December 26, 1986, to May 15, 1987, were identified, and the charts of the patients involved were reviewed to determine whether the drug's use was appropriate or inappropriate according to pre-established guidelines for indication, dose, dosage interval, and duration of therapy or prophylaxis. The oral route of administration was considered appropriate for patients who were taking other oral medications or who were on a diet of at least clear fluids. The acquisition cost of metronidazole from January to June 1987 was used to determine the potential cost avoidance that would result if (1) all types of inappropriate use were corrected, or (2) only the inappropriate route of administration were corrected. A total of 104 courses of therapy in 98 patients were evaluated, of which 76 were therapeutic and 28 were prophylactic. Of the 104 courses, 62% were found to be inappropriate by at least one of the criteria for appropriate use, excluding route of administration. Of the 893 doses of metronidazole administered by the i.v. route, 424 (47%) could have been given orally. A drug cost analysis revealed that $3954 (48% of the total hospital expenditure for metronidazole) could have been saved by substituting oral metronidazole for i.v. metronidazole when possible. If all criteria for appropriate use of metronidazole had been followed, $5977 could have been saved, which represents 71% of the current hospital expenditure for metronidazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the contribution of clinical pharmacists: inpatient care and cost reduction.

Clinical pharmacists in this study hospital reported 1027 interventions in patient drug therapy over two time periods of three and two weeks, respectively. These interventions were subjected to self and peer reviews and to cost-avoidance evaluation. The most frequent type of intervention was recommendations related to drug selection (29.6 percent). Recommendations were not implemented by physicians in only 10.2 percent of the cases. The perceived impact of these interventions on the quality, cost, or both was found by the peer reviewers to occur in 58.5, 16.1 and 25.6 percent of the cases, respectively. Also, when peer reviewed for clinical significance, 983 of these interventions were judged to improve drug therapy to an acceptable level based on the professional literature, and 36 were deemed very significant in terms of saving patients' lives or preserving major organ functions. Of the 983 interventions rendering drug therapy to an appropriate level, 398 were deemed to have cost-avoidance impact; of this number a 25 percent random sample was subjected to cost-avoidance evaluation. Realized cost-avoidance averaged $242 for each intervention implemented. When extrapolated annually, $364,900 was the net realized cost-avoidance after discounting for the cost of providing clinical pharmacy services. An average cost-avoidance of $860.50 was calculated for each intervention made by pharmacists, but not followed by physicians, for an annual potential cost-avoidance of $532,650. In all, clinical pharmacists had the potential to save $897,550 annually in hospital resources if all their interventions had been accepted and implemented.

Effect of pharmacist interventions on drug therapy costs in a surgical intensive-care unit

The effect of interventions by a clinical pharmacist on the cost of drug therapy in a 14-bed surgical intensive-care unit (SICU) was evaluated. The SICU pharmacist provides both distributive and clinical services from a modified satellite pharmacy five days each week. During a 13-week study period that comprised 65 days, the pharmacist documented all interventions that resulted in a discontinuation of or change in drug therapy, all nonformulary-drug requests, the detection and avoidance of problems related to drug therapy, and the enrollment of patients in investigational drug studies (for which the pharmacy department received monetary remuneration). The effect of these interventions on the costs of drug therapy was calculated using drug acquisition costs and, for i.v. preparations, the cost of the i.v. fluid and the cost of preparing and checking the product. A total of 332 interventions during the study period represented $18,030 in potential cost avoidance, which would extrapolate to an annual cost avoidance of $72,122. The majority of interventions involved discontinuations of or changes in drug therapy, most often involving antimicrobials. This pharmacist had a positive impact on the cost of drug therapy in the SICU.