Orlando, Fla.—Cost-saving strategies were front and center at the American Society of Health-System Pharmacists (ASHP) 2013 Midyear Clinical Meeting. Ranging from a simple yet highly effective metered dose inhaler switch to a revamping of a hospital’s medication reconciliation program, the initiatives saved scarce health care dollars, maintained or improved patient care and streamlined pharmacy operations.
In this, the first of a two-part series, Pharmacy Practice News details the initiatives and offers lessons learned for health systems facing similar fiscal challenges.
Switch to Nebulizer A High-Impact Move
Implementing a system-wide change that requires little investment, is seamless in execution and has the potential to save more than $1 million annually may seem like a tall order, but that is precisely what was accomplished by a team of clinicians, respiratory therapists and pharmacists at Ascension Health, a national network of nonprofit hospitals based in St. Louis (poster 5-051).
Roy Guharoy, PharmD, MBA, who is the chief pharmacy officer and vice president at Ascension Health, said this multidisciplinary group set out to find a product that addressed the shortcomings of using metered dose inhalers (MDIs) to administer ipratropium/albuterol in ventilated patients. “Drug penetration with MDIs can vary depending on the individual respiratory therapist’s technique,” Dr. Guharoy explained. “And because MDIs add air pressure, they can disrupt ventilator settings and require respiratory therapist monitoring.”
There is also significant waste associated with MDIs, he said, noting his health system spends $2.4 million annually on MDIs.After reviewing alternative products, pharmacists at St John Providence System, an Ascension hospital in Detroit, switched from MDIs to a multiuse nebulizer (Aeroneb Pro, Aerogen). The switch had profound effects, Dr. Guharoy said at the ASHP meeting. “The average cost on a per-patient basis dropped from $191 with MDIs to $46 with the nebulizer,” he noted.
Because the new nebulizers are not replaced as often as MDIs and do not add to ventilator airflow, respiratory therapists spend less time managing the new devices. “We expect to save between $870,000 and $1.7 million based on a 50% to 100% [Ascension Health] system-wide conversion to the new nebulizers,” Dr. Guharoy said.
Although they have not measured the clinical effects of the switch, Dr. Guharoy said nebulized administration is associated with “much better lung penetration and better therapeutic outcomes.”
Reaping Rewards Via Pharmacist Rounding
Mate Soric, PharmD, a clinical internal medicine pharmacist at the University Hospitals Geauga Medical Center, a community hospital in Chardon, Ohio, hopes the financial effects of a pharmacy inpatient rounding service he helped establish in 2011 will nudge other community hospitals to add pharmacists to their own rounds (poster 5-169).
“We’ve achieved savings in inpatient drug expenditures that more than justify the position,” said Dr. Soric, who is also an assistant professor in the Department of Pharmacy Practice at Northeast Ohio Medical University in Rootstown.
The researcher collected data from 1,049 patients examined between Jan. 1 and Dec. 31, 2011, by an internal or family medicine physician team that included a clinical pharmacist as well as pharmacy residents and students. The 1,656 interventions performed by the group included issuing recommendations for drug therapy optimization, such as adding a medication to a treatment regimen according to published guidelines (32.6%), advising caregivers on techniques to prevent adverse events (AE) (19.3%), providing drug information to patients and other providers (19.1%) and adjusting drug dosages (13.2%). Additionally, they made cost-savings recommendations (8.5%), such as switching from more expensive IV formulations to oral formulations (8.5%), and ordered laboratory tests that physicians had not overloooked, in order to monitor the safety and efficacy of a therapy (7.4%), Dr. Soric noted.
The average total per-patient drug expenditure in this group was $285, significantly lower than the average $412 for 1,959 patients in a control group seen during the same period by internal or family medicine rounding teams without a pharmacist (P=0.01), he reported.
Some of the more striking savings occurred in patients with pneumonia, Dr. Soric noted. Drug costs in the patients seen by a pharmacist during rounds equaled $320 vs. $503 when no pharmacist was present on the rounding team (P=0.0006), he said, adding that “the impact here was mostly due to antimicrobial stewardship–style interventions.”
Dr. Soric emphasized the methodologic strength of the cost–benefit analysis, noting that most studies “look at potential cost avoidance based on estimated cost savings per intervention. We instead looked directly at medication expenditures in patients seen or not seen by pharmacists during rounds,” he said. “And since there were no differences in the severity of illness or lengths of hospital stay between the groups, the cost impact is likely attributable to the presence of the pharmacist.”
Med Reconciliation a Safety Net
Sumana Alex, PharmD, BCPS, a clinical pharmacy specialist at the Veterans Affairs Medical Center in Washington, D.C., shared her own experience conducting daily rounds with one of the VA’s six internal medicine teams between August and October 2102 (poster 3-076).
Dr. Alex’s duties included monitoring inpatient drug therapy, interviewing patients upon admission to obtain their medication history, counseling patients at discharge, conducting medication reconciliations at admission and discharge, and following up with high-risk patients after discharge. Over a three-month study period, she reviewed 160 admissions, 145 discharges and conducted 179 inpatient interventions.
The errors she detected during admission medication reconciliation and during inpatient hospital stays included 40 cases of wrong doses, 33 cases of diagnoses not receiving drug treatment and 21 unintentional drug omissions (Figure 1). She also identified 104 medication discrepancies at the time of discharge, 89 of which she was able to resolve before patients actually left the hospital (Figure 2).
Figure 1. Frequency of errors detected during admission medication reconciliation and hospital stay.
- Adverse drug reaction
- Drug-disease interaction
- Drug-drug interaction
- Error – administration
- Error – dispensing
- Omission of drug orders
Figure 2. Discharge medication discrepancies.
- Omission of drug allergy
- Discontinued drugs in profile
- Drug-drug-disease interaction
- Duplicate instructions for same drug
- Omission of medication orders
- Extraneous orders
- Dispensing/ordering errors
- Inaccurate discharge instructions
- Not alerting
“A review team of one pharmacist and two hospitalists deemed that 28% of the mistakes I identified would have potentially been harmful if not for my interventions,” she noted. Potential mistakes that were averted included administration of contraindicated drugs, or drugs that had been assigned incorrect doses, frequencies or routes of administration. Dr. Alex said 91% of her recommendations were accepted by physicians.
The researchers also documented $186,121 in costs attributable to 11 significant drug-related AEs that occurred in the study patients either before or during admission. As a result of pharmacist interventions in these and other events, the hospital saved an estimated $169,070 that would have been spent on the AE-related treatments, Dr. Alex noted.
The interventions also led to an estimated $9,714 in savings directly attributable to medication changes. “These direct, medication-related savings would have been three times higher in private hospitals, but the VA obtains drugs at a lower acquisition cost,” she said.
Turning Budget Cuts Into Process Improvements
The $3.8 million in spending that Cindy Jeter, CPhT, CPP, BGS, helped a 969-bed academic medical center pharmacy cut after being hit with a 10% budget reduction is only a partial testament to the success of her approach (poster 3-006). “Most importantly, the pharmacy met its goal by trimming its drug spend, not by eliminating staff,” said Ms. Jeter, a supply chain management consultant with McKesson Health Systems’ Pharmacy Optimization Team in Springdale, Ark.
The achievement, at the Thomas Jefferson University Hospital, in Philadelphia, was the result of several initiatives, Ms. Jeter explained. Pharmacy staff now ensures that all eligible individuals are enrolled in patient assistance programs, for example. That effort helped the pharmacy recoup $734,325 worth of medications and devices from manufacturers over a one-year period (Figure 3).
Figure 3. Distribution of $3.8 million in spending cuts at a 969-bed academic medical center
Capturing more of the vendor market share also helped the pharmacy negotiate larger discounts, she said, and contributed to a further $327,231 shave off its one-year drug spend.
With Ms. Jeter’s help, pharmacy has also refined its inventory management approach, applying stricter criteria for use of nonformulary items and ordering and dispensing drugs on short supply only through the pharmacy storeroom, in order to reduce waste, for example. These measures and the broader initiative have diminished the value of the pharmacy’s inventory by $2.7 million compared with the six months before the project, Ms. Jeter said.
“The pharmacy now has an additional 8.2% budget reduction to deal with for the coming year,” Ms. Jeter said, “but through our collaborative\ training and development of policies and procedures, staff will be able to maintain the progress they made and accomplish additional successes.”
Off Hours a Potential Revenue Generator
Until March 2013, off-hour medication orders were managed differently among Summa Health System’s seven hospitals: Some of the facilities relied on two Summa hospitals that had off-hour pharmacists; one contracted with a for-profit vendor; and two had their own pharmacists review orders the following morning (poster 3-008).
“The situation was costly and left the door open to medication errors,” said Kenneth Komorny, PharmD, who is the system director of pharmacy for four of Summa’s hospitals, which are located in Akron, Ohio.
The situation also prompted Dr. Komorny and Summa’s other pharmacy directors to pitch the idea of a centralized, in-house remote order-processing center to hospital leadership.
“Once we got approval, we needed to create the system from scratch,” he recalled. “This meant hiring a site manager to create the hardware and software infrastructure, to train each of the pharmacy systems, to develop policies and procedures and to devise a standard workflow.”
Between March 4 and May 31, 2013, during which time all five of the Summa hospitals without off-hour pharmacists were gradually brought online, the newly formed service enabled participants to process 35,883 orders, field 952 phone calls and conduct 290 clinical interventions.
Although no objective tool was used to document the clinical impact of those interventions, facilities reported a lowered incidence of medication errors during the evening and night shifts, Dr. Komorny reported. The reduction was attributable to several factors, including faster time to verification, fewer overrides at the automated dispensing machine (Figure 4) and the availability of the pharmacist for questions, the researchers found.
Figure 4. Profile overrides at the ADC (Pyxis) for a Summa Health System facility after adding
Moreover, nursing satisfaction improved at all facilities based on nursing comments, with some facilities reporting “vast improvement,” Dr. Komorny said. Pharmacy staff satisfaction also improved due to lower workload regarding other facilities, he noted.
There was one additional benefit: pharmacists at the non–24-hour facilities no longer were required to spend the first one to two hours of their shift verifying orders from the overnight period. As a result, “pharmacists can spend more time on clinical issues and improving patient care,” he said.
As for cost savings, the service generated an estimated $14,398 in revenue from per-order processing fees during the three-month period, with the added bonus of being provided “at the least possible cost” to Summa’s hospitals, Dr. Komorny said.
“The one Summa joint venture affiliate that had been using a for-profit service reduced its costs by more than 60% by converting to our internal service,” which was totally home-grown, he added. “Our plan now is to generate further revenue for Summa by offering the service at a marked-up but affordable, price-competitive rate to non-Summa hospitals.”
Drs. Guharoy, Soric, Alex and Komorny reported no relevant financial conflicts of interest.