- Email: [email protected]
Budget Impact Analysis of Conversion from Intravenous to Oral Medication When Clinically Eligible for Oral Intake
Clinical Therapeutics/Volume 33, Number 11, 2011
Budget Impact Analysis of Conversion from Intravenous to Oral Medication When Clinically Eligible for Oral Intake Brandyn D. Lau, SB1; Brian L. Pinto, PharmD2; David R. Thiemann, MD1,3; and Christoph U. Lehmann, MD4 1
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, Maryland; 3Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 4Department of Pediatrics and Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland 2
ABSTRACT Background: Many patients receive intravenous (IV) medication while clinically eligible for oral (PO) medication intake, which represents a potential for safety improvement and substantial medication cost reduction. Objective: We analyzed the potential hospital medication budget impact associated with converting from IV to PO administration of 4 targeted IV medications, each representing a different class of drug, when patients were clinically eligible for PO medication intake. Methods: Chlorothiazide, voriconazole, levetiracetam, and pantoprazole were identified as 4 costly IV medications with highly bioavailable PO equivalents. Data were extracted from the computerized provider order entry (CPOE) system at Johns Hopkins Hospital and analyzed to determine the doses administered of the 4 identified IV medications, while patients were concurrently receiving PO intake. Results: More than two thirds of adult inpatients were administered IV chlorothiazide, voriconazole, levetiracetam, or pantoprazole while concurrently receiving PO intake. This use of expensive IV medications rather than PO equivalents in patients eligible for PO medication intake added $1,166,759.70 to the yearly cost of care at Johns Hopkins Hospital. Conclusions: Efforts to remind physicians to convert patient orders from IV to PO medications in patients eligible for PO medication intake could have a considerable impact on the total cost of health care. (Clin Ther. 2011;33:1792–1796) © 2011 Elsevier HS Journals, Inc. All rights reserved.
INTRODUCTION According to the Centers for Medicare and Medicaid Services, ⬃12% of the US health care expenditures in
1792
2009 ($293.2 billion) were due to medications and nondurable medical products.1 Inpatient hospital pharmacies are estimated to account for between 7% and 10% of a hospitals’ total operating cost.2 According to the American Society of Health-System Pharmacists, the largest portion of any inpatient hospital pharmacy budget is medication cost,3 representing ⬃80% of the total pharmacy budget.2 The high cost of medication incurred by the hospital, representing between 5.6% and 8% of the total hospital budget, substantially contributes to the total cost of inpatient care. Past studies have shown that conversion from intravenous (IV) to oral (PO) medication when patients are clinically eligible may reduce the costs associated with IV administration.4 When admitted to the hospital, many patients are initially started on IV medication because their clinical conditions may prohibit the use of PO medication (eg, “nothing-by-mouth” [NPO] status pre/post-surgery or during mechanical ventilation). When a patient’s condition improves and the patient can tolerate PO intake, medications can be transitioned from IV to PO forms. Conversion from IV to PO may reduce the need for IV access, which carries a higher risk of hospital-acquired bloodstream infections,5 phlebitis, cellulitis, and severe adverse events associated with infiltration6 for the patient. Further hospitalization cost saving may be achieved through reduced medication dispensing and administration cost,7 reduced need for IV access, and reduced frequency of complication.
Accepted for publication September 22, 2011. doi:10.1016/j.clinthera.2011.09.030 0149-2918/$ - see front matter © 2011 Elsevier HS Journals, Inc. All rights reserved.
Volume 33 Number 11
B.D. Lau et al.
Table I. Intravenous (IV) medication administrations while adult inpatients were concurrently eligible for oral (PO) medication intake at Johns Hopkins Hospital in the Department of Medicine during 2010. Medication Chlorothiazide Levetiracetam Voriconazole Pantoprazole
Total No. of IV Doses Administered
IV Doses Administered While PO Eligible
Proportion of Doses Administered While PO Eligible
579 797 128 9401
502 546 94 6162
86.7 68.9 73.4 65.6
Many commonly used IV medications are expensive. Conversion from IV medications to less expensive PO equivalents could result in a cost reduction. Three frequently used drugs that show a significant cost difference between IV and PO forms are chlorothiazide,* levetiracetam,† and voriconazole‡ (Table I). Based on the average wholesale price (AWP) from the 2011 Red Book, IV chlorothiazide is ⬎200 times as expensive as its PO equivalent.8 Pantoprazole § is a medication for which the difference between IV and PO forms is also extensive8 and is ordered with high frequency (⬎20 doses ordered/ day) among adult inpatients. All 4 medications are commercially available in IV and PO formulations and have equivalent bioavailability via either route of administration. Chlorothiazide, levetiracetam, voriconazole, and pantoprazole are commonly used in the adult inpatient setting. In addition, metolazone is a PO alternative given to patients transitioning from IV chlorothiazide. Providers have to remember to transition medications to PO from IV forms. Relying on busy providers to remember generates a potential point of failure that results in prolonged IV medication use. Several studies have evaluated conversion from IV to PO medications when the patient’s clinical condition allows via pharmacy intervention or a CPOE-generated reminder. Frequently, the majority of targeted medications in IV to PO conversion studies are antimicrobials, due to their high frequency of use and highly bioavailable PO forms.4,5,9 –14 In the present study, we analyzed the potential hospital medication budget impact associated with con*Trademark: Diuril® (Lundbeck, Deerpark, Illinois). † Trademark: Keppra® (UCB Pharma, Smyrna, Georgia). ‡ Trademark: VFend® (Pfizer, New York, New York). § Trademark: Protonix® (Pfizer-Wyeth, New York, New York).
November 2011
version from IV to PO medication for the 4 targeted IV medications, each representing a different class of drug, when patients were clinically eligible for PO medication intake.
METHODS Johns Hopkins Hospital is a 982-bed, urban, tertiary care teaching hospital in Baltimore, Maryland. In this descriptive utilization study with institutional review board approval, the hospital’s computerized provider order entry (CPOE) system (Sunrise Clinical Manager by Allscripts) was queried (by C.U.L.) to report the total number of doses of IV chlorothiazide, levetiracetam, voriconazole, and pantoprazole administered between January 1, 2010 and December 31, 2010 for all adult inpatients in the Department of Medicine. Oral medication doses of these medications and pantoprazole infusions were excluded from this study. The CPOE system was then queried to determine the timing of all diet orders for this patient group, including NPO orders. The IV medication administration task was linked to the diet order status of the patient at the time the medication dose was administered. A patient who had an order for enteral nutrition at the time the IV medication was due was considered eligible for PO medication intake. In cases in which the medication administration task was unmatched to diet status, due to the medication task preceding any diet order, the medical record was manually reviewed for active PO medication orders at the time the IV medication was due to establish clinical eligibility for PO medication intake. The results were used to determine the potential annual cost reduction and compared to the total number of doses ordered for each of the 4 identified IV medications.
1793
Clinical Therapeutics
1794
$178,591.52 $116,019.54 $10,023.22 $862,125.42 $1,166,759.70 $1352.96 $1450.24 $400.93 $680.98 502 546 94 6162 132 80 25 1266
AWP ⫽ average wholesale price; IV ⫽ intravenous. *PO equivalent is metolazone.
$355.76 $212.49 $106.63 $139.91 $357.24 (500-mg vial) $1.48 (5-mg tab) $216.00 (500-mg vial) $3.51 (500-mg tab) $153.54 (200-mg vial) $46.91 (200-mg tab) $144.00 (40-mg vial) $4.09 (40-mg tab) Chlorothiazide* Levetiracetam Voriconazole Pantoprazole Total Cost Reduction
IV AWP Cost/Dose
In this study, we evaluated the IV administration of 4 drugs when the patients were potentially eligible for PO medication administration. Theoretically, transitioning from IV to PO medication among patients whose clinical condition allows for PO medication intake may lead to a substantial reduction in annual cost of hospitalization. In the present study, in most cases, the 4 identified medications were given intravenously despite a clinical condition that may allow for PO medication intake. As anticipated, a substantial cost saving potential was seen in all 4 medication classes studied. The normalized analysis shows that chlorothiazide and levetiracetam had the greatest cost savings per patient (Ta-
Medication
DISCUSSION
IV Doses Cost Savings/ No. of Administered Potential Cost Potential Cost PO AWP Cost/Dose Dose Patients While PO Eligible Savings/Patient Reduction/Year
During 2010, a total of 10,905 doses of the 4 identified IV medications were administered among 1410 adult inpatients in the Department of Medicine, representing 1503 unique patient–medication pairs. Two patients received 3 of the medications studied and 89 received 2. Ninety-two doses of IV medication (0.8%) were unmatched to diet orders, for which a chart review was conducted to determine clinical eligibility for PO medication intake. We determined the proportion of IV administrations of the 4 identified medications while patients were concurrently eligible for PO doses. Among all adult inpatients in the Department of Medicine, 86.7% receiving IV chlorothiazide, 68.9% receiving IV levetiracetam, 73.4% receiving IV voriconazole, and 65.6% receiving IV pantoprazole were receiving concurrent PO intake (Table I). Using medication costs established by the 2011 Red Book AWP,8 a 1-year budget impact analysis of conversion from IV to PO medication among patients eligible for PO medication intake yielded a total potential cost reduction of $1,166,759.70 for the year 2010 at Johns Hopkins Hospital (Table II). The total annual cost savings for conversion from IV chlorothiazide to PO metolazone was calculated to be $178,591.52. Annual cost savings for conversion from IV to PO were $116,019.54 for levetiracetam, $10,023.22 for voriconazole, and $862,125.42 for pantoprazole. The potential maximum cost savings was normalized to potential cost savings per patient for each drug studied. The cost savings per patient for conversion from IV chlorothiazide to PO metolazone was calculated to be $1352.96. Normalized savings for IV to PO conversion were $1450.24 for levetiracetam, $400.93 for voriconazole, and $680.98 for pantoprazole.
Table II. Potential cost savings of oral (PO) medication conversion among adult inpatients eligible for PO medication intake at Johns Hopkins Hospital in the Department of Medicine during 2010.
RESULTS
Volume 33 Number 11
B.D. Lau et al. ble II). It is important to note that our analysis included only the medication cost reduction and not costs associated with IV placement, maintenance, drug administration, monitoring, hospital-acquired IV site infection, adverse events, or resulting delayed length of stay, which may potentially add thousands of dollars to the cost of hospitalization.5 We recognize that eligibility for some PO intake is not an exclusive indicator for PO medication use and that our results represent the maximum potential for medication cost reduction. Patients may be converted back to IV medications because their diet order changes. Our study took these re-conversions into consideration, as IV dose administrations were counted only when the patient was ordered a PO diet. Further limiting the potential savings is the fact that a provider may choose the IV form for a specific reason over the PO form such as use of IV pantoprazole in patients with a history of erosive esophagitis or IV voriconazole for invasive aspergillosis. However, it is highly unlikely that all of the patients concurrently ordered IV medication and PO intake were ineligible for IV to PO conversion of these 4 identified medications. Even a small increase in conversion when the patient is identified as clinically eligible would have a substantial impact due to the considerable difference in cost between the IV and PO forms. A limitation of our study is that generalizability from a budget impact analysis is complicated by many factors, including stability of case mix over time, comparability of cases, product prices, and medical practice patterns in an academic medical center to community practice in other institutions.15 Another limitation is the absence of data on PO dose administrations. We requested approval for IV medication doses only and thus were unable to analyze how frequently patients were switched between the different routes and how long any switch from IV to PO medication was delayed. Teich et al9 reported cost savings at Brigham and Women’s Hospital with a pharmacist-initiated alert for IV to PO medication conversion, when clinical indicators for PO medication intake, including PO diet and other PO medication orders, were present. This approach required an additional step of communication between a pharmacist and the physician in order to convert the medication route. Fischer et al10 initiated a follow-up study that targeted physicians directly by generating a reminder in CPOE at the time IV medication is prescribed when patients are receiving an oral
November 2011
diet or other oral medication. This study showed a statistically significant decrease in IV medication use and a corresponding increase in PO medication use. In a separate study, Galanter et al11 demonstrated overall compliance rates of 18.7% for a CPOE-generated alert suggesting conversion from IV to PO medication at the time medications are ordered. Although this study does not report the cost reduction associated with implementing this alert, this rate of compliance would reduce costs at our institution by tens, if not hundreds, of thousands of dollars each year for these 4 medications alone.
CONCLUSIONS Developing clinical decision support is time consuming and costly. Our findings, however, illustrate a need to develop a clinical alert within the CPOE system to remind providers to convert medications from IV to PO forms when established eligibility criteria for PO medication intake are met. When building clinical decision support to prompt providers to change medication route, developers must to take into consideration the potential benefit per interruption of an already busy clinician. Based on total cost alone, pantoprazole appeared to be a low-hanging fruit for future decision support. However, considering time, job satisfaction, and the cognitive cost of interrupting providers, developers may consider focusing on drugs with high savings per interruption, such as levetiracetam and chlorothiazide.
ACKNOWLEDGMENTS All authors contributed to, reviewed, and agree with the findings in this manuscript and report no financial conflicts of interest.
REFERENCES 1. Centers for Medicare and Medicaid Services. National Health Expenditures 2009 Highlights. https://www.cms. gov/NationalHealthExpendData/downloads/highlights. pdf. Accessed May 16, 2011. 2. Weber RJ. Core competencies in hospital pharmacy practice: department financial management. Hosp Pharm. 2006; 41:689 – 694. 3. ASHP guidelines on medication cost management strategies for hospitals and health systems. Am J Health Syst Pharm. 2008;65:1368 –1384. 4. Nadeau MC, Kuti EL. Clinical and economic impact of intravenous to oral conversion therapy programs. Conn Med. 2011;75:25–29.
1795
Clinical Therapeutics 5. Davis SL, Delgado JG, McKinnon PS. Pharmacoeconomic considerations associated with the use of intravenous-tooral moxifloxacin for community-acquired pneumonia. Clin Infect Dis. 2005; 41(Suppl 2):S136–143. 6. KagelEM,RayanGM.Intravenouscatheter complications in the hand and forearm. J Trauma. 2004;56:123–127. 7. Cunha BA. Oral versus IV treatment for catheter-relatedbloodstreaminfections. EmergInfectDis.2007;13:1800–1801. 8. Red Book: Pharmacy’s Fundamental Reference. New York, NY: Thomson Reuters, 2011. 9. Teich JM, Petronzio AM, Gerner JR, et al. An information system to promote intravenous-to-oral medication conversion. Proc AMIA Symp 1999:415– 419. 10. Fischer MA, Solomon DH, Teich JM, Avorn J. Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients. Arch Intern Med. 2003;163:2585–2589. 11. Galanter W, Liu XF, Lamber BL. Analysis of computer alerts suggesting oral medication use during computerized order entry of IV medications. Am J Health Syst Pharm. 2010; 67:1101–1105. 12. Glemaud I. Use of a physician order entry system to identify opportunities for intravenous to oral levofloxacin conversion. Am J Health Syst Pharm. 2000;57(Suppl 3):S14 –S16. 13. Kuti JL, Le TN, Nightingale CH, et al. Pharmacoeconomics of a pharmacist managed program for automatically converting levofloxacin route from IV to oral. Am J Health Syst Pharm. 2002;59:2209 –2215. 14. Przybylski KG, Rybak MJ, Martin PR, et al. Pharmacist-initiated program of intravenous to oral antibiotic conversion. Pharmacotherapy. 1997;17:271–276. 15. Mauskopf JA, Sullivan SD, Annemans L, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices— budget impact analysis. Value Health. 2007;10:336 –347.
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Address correspondence to: Brandyn D. Lau, SB, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument Street, Suite 8064, Baltimore, MD 21287. E-mail: [email protected]
Volume 33 Number 11
Budget Impact Analysis of Conversion from Intravenous to Oral Medication When Clinically Eligible for Oral Intake Brandyn D. Lau, SB1; Brian L. Pinto, PharmD2; David R. Thiemann, MD1,3; and Christoph U. Lehmann, MD4 1
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, Maryland; 3Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 4Department of Pediatrics and Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland 2
ABSTRACT Background: Many patients receive intravenous (IV) medication while clinically eligible for oral (PO) medication intake, which represents a potential for safety improvement and substantial medication cost reduction. Objective: We analyzed the potential hospital medication budget impact associated with converting from IV to PO administration of 4 targeted IV medications, each representing a different class of drug, when patients were clinically eligible for PO medication intake. Methods: Chlorothiazide, voriconazole, levetiracetam, and pantoprazole were identified as 4 costly IV medications with highly bioavailable PO equivalents. Data were extracted from the computerized provider order entry (CPOE) system at Johns Hopkins Hospital and analyzed to determine the doses administered of the 4 identified IV medications, while patients were concurrently receiving PO intake. Results: More than two thirds of adult inpatients were administered IV chlorothiazide, voriconazole, levetiracetam, or pantoprazole while concurrently receiving PO intake. This use of expensive IV medications rather than PO equivalents in patients eligible for PO medication intake added $1,166,759.70 to the yearly cost of care at Johns Hopkins Hospital. Conclusions: Efforts to remind physicians to convert patient orders from IV to PO medications in patients eligible for PO medication intake could have a considerable impact on the total cost of health care. (Clin Ther. 2011;33:1792–1796) © 2011 Elsevier HS Journals, Inc. All rights reserved.
INTRODUCTION According to the Centers for Medicare and Medicaid Services, ⬃12% of the US health care expenditures in
1792
2009 ($293.2 billion) were due to medications and nondurable medical products.1 Inpatient hospital pharmacies are estimated to account for between 7% and 10% of a hospitals’ total operating cost.2 According to the American Society of Health-System Pharmacists, the largest portion of any inpatient hospital pharmacy budget is medication cost,3 representing ⬃80% of the total pharmacy budget.2 The high cost of medication incurred by the hospital, representing between 5.6% and 8% of the total hospital budget, substantially contributes to the total cost of inpatient care. Past studies have shown that conversion from intravenous (IV) to oral (PO) medication when patients are clinically eligible may reduce the costs associated with IV administration.4 When admitted to the hospital, many patients are initially started on IV medication because their clinical conditions may prohibit the use of PO medication (eg, “nothing-by-mouth” [NPO] status pre/post-surgery or during mechanical ventilation). When a patient’s condition improves and the patient can tolerate PO intake, medications can be transitioned from IV to PO forms. Conversion from IV to PO may reduce the need for IV access, which carries a higher risk of hospital-acquired bloodstream infections,5 phlebitis, cellulitis, and severe adverse events associated with infiltration6 for the patient. Further hospitalization cost saving may be achieved through reduced medication dispensing and administration cost,7 reduced need for IV access, and reduced frequency of complication.
Accepted for publication September 22, 2011. doi:10.1016/j.clinthera.2011.09.030 0149-2918/$ - see front matter © 2011 Elsevier HS Journals, Inc. All rights reserved.
Volume 33 Number 11
B.D. Lau et al.
Table I. Intravenous (IV) medication administrations while adult inpatients were concurrently eligible for oral (PO) medication intake at Johns Hopkins Hospital in the Department of Medicine during 2010. Medication Chlorothiazide Levetiracetam Voriconazole Pantoprazole
Total No. of IV Doses Administered
IV Doses Administered While PO Eligible
Proportion of Doses Administered While PO Eligible
579 797 128 9401
502 546 94 6162
86.7 68.9 73.4 65.6
Many commonly used IV medications are expensive. Conversion from IV medications to less expensive PO equivalents could result in a cost reduction. Three frequently used drugs that show a significant cost difference between IV and PO forms are chlorothiazide,* levetiracetam,† and voriconazole‡ (Table I). Based on the average wholesale price (AWP) from the 2011 Red Book, IV chlorothiazide is ⬎200 times as expensive as its PO equivalent.8 Pantoprazole § is a medication for which the difference between IV and PO forms is also extensive8 and is ordered with high frequency (⬎20 doses ordered/ day) among adult inpatients. All 4 medications are commercially available in IV and PO formulations and have equivalent bioavailability via either route of administration. Chlorothiazide, levetiracetam, voriconazole, and pantoprazole are commonly used in the adult inpatient setting. In addition, metolazone is a PO alternative given to patients transitioning from IV chlorothiazide. Providers have to remember to transition medications to PO from IV forms. Relying on busy providers to remember generates a potential point of failure that results in prolonged IV medication use. Several studies have evaluated conversion from IV to PO medications when the patient’s clinical condition allows via pharmacy intervention or a CPOE-generated reminder. Frequently, the majority of targeted medications in IV to PO conversion studies are antimicrobials, due to their high frequency of use and highly bioavailable PO forms.4,5,9 –14 In the present study, we analyzed the potential hospital medication budget impact associated with con*Trademark: Diuril® (Lundbeck, Deerpark, Illinois). † Trademark: Keppra® (UCB Pharma, Smyrna, Georgia). ‡ Trademark: VFend® (Pfizer, New York, New York). § Trademark: Protonix® (Pfizer-Wyeth, New York, New York).
November 2011
version from IV to PO medication for the 4 targeted IV medications, each representing a different class of drug, when patients were clinically eligible for PO medication intake.
METHODS Johns Hopkins Hospital is a 982-bed, urban, tertiary care teaching hospital in Baltimore, Maryland. In this descriptive utilization study with institutional review board approval, the hospital’s computerized provider order entry (CPOE) system (Sunrise Clinical Manager by Allscripts) was queried (by C.U.L.) to report the total number of doses of IV chlorothiazide, levetiracetam, voriconazole, and pantoprazole administered between January 1, 2010 and December 31, 2010 for all adult inpatients in the Department of Medicine. Oral medication doses of these medications and pantoprazole infusions were excluded from this study. The CPOE system was then queried to determine the timing of all diet orders for this patient group, including NPO orders. The IV medication administration task was linked to the diet order status of the patient at the time the medication dose was administered. A patient who had an order for enteral nutrition at the time the IV medication was due was considered eligible for PO medication intake. In cases in which the medication administration task was unmatched to diet status, due to the medication task preceding any diet order, the medical record was manually reviewed for active PO medication orders at the time the IV medication was due to establish clinical eligibility for PO medication intake. The results were used to determine the potential annual cost reduction and compared to the total number of doses ordered for each of the 4 identified IV medications.
1793
Clinical Therapeutics
1794
$178,591.52 $116,019.54 $10,023.22 $862,125.42 $1,166,759.70 $1352.96 $1450.24 $400.93 $680.98 502 546 94 6162 132 80 25 1266
AWP ⫽ average wholesale price; IV ⫽ intravenous. *PO equivalent is metolazone.
$355.76 $212.49 $106.63 $139.91 $357.24 (500-mg vial) $1.48 (5-mg tab) $216.00 (500-mg vial) $3.51 (500-mg tab) $153.54 (200-mg vial) $46.91 (200-mg tab) $144.00 (40-mg vial) $4.09 (40-mg tab) Chlorothiazide* Levetiracetam Voriconazole Pantoprazole Total Cost Reduction
IV AWP Cost/Dose
In this study, we evaluated the IV administration of 4 drugs when the patients were potentially eligible for PO medication administration. Theoretically, transitioning from IV to PO medication among patients whose clinical condition allows for PO medication intake may lead to a substantial reduction in annual cost of hospitalization. In the present study, in most cases, the 4 identified medications were given intravenously despite a clinical condition that may allow for PO medication intake. As anticipated, a substantial cost saving potential was seen in all 4 medication classes studied. The normalized analysis shows that chlorothiazide and levetiracetam had the greatest cost savings per patient (Ta-
Medication
DISCUSSION
IV Doses Cost Savings/ No. of Administered Potential Cost Potential Cost PO AWP Cost/Dose Dose Patients While PO Eligible Savings/Patient Reduction/Year
During 2010, a total of 10,905 doses of the 4 identified IV medications were administered among 1410 adult inpatients in the Department of Medicine, representing 1503 unique patient–medication pairs. Two patients received 3 of the medications studied and 89 received 2. Ninety-two doses of IV medication (0.8%) were unmatched to diet orders, for which a chart review was conducted to determine clinical eligibility for PO medication intake. We determined the proportion of IV administrations of the 4 identified medications while patients were concurrently eligible for PO doses. Among all adult inpatients in the Department of Medicine, 86.7% receiving IV chlorothiazide, 68.9% receiving IV levetiracetam, 73.4% receiving IV voriconazole, and 65.6% receiving IV pantoprazole were receiving concurrent PO intake (Table I). Using medication costs established by the 2011 Red Book AWP,8 a 1-year budget impact analysis of conversion from IV to PO medication among patients eligible for PO medication intake yielded a total potential cost reduction of $1,166,759.70 for the year 2010 at Johns Hopkins Hospital (Table II). The total annual cost savings for conversion from IV chlorothiazide to PO metolazone was calculated to be $178,591.52. Annual cost savings for conversion from IV to PO were $116,019.54 for levetiracetam, $10,023.22 for voriconazole, and $862,125.42 for pantoprazole. The potential maximum cost savings was normalized to potential cost savings per patient for each drug studied. The cost savings per patient for conversion from IV chlorothiazide to PO metolazone was calculated to be $1352.96. Normalized savings for IV to PO conversion were $1450.24 for levetiracetam, $400.93 for voriconazole, and $680.98 for pantoprazole.
Table II. Potential cost savings of oral (PO) medication conversion among adult inpatients eligible for PO medication intake at Johns Hopkins Hospital in the Department of Medicine during 2010.
RESULTS
Volume 33 Number 11
B.D. Lau et al. ble II). It is important to note that our analysis included only the medication cost reduction and not costs associated with IV placement, maintenance, drug administration, monitoring, hospital-acquired IV site infection, adverse events, or resulting delayed length of stay, which may potentially add thousands of dollars to the cost of hospitalization.5 We recognize that eligibility for some PO intake is not an exclusive indicator for PO medication use and that our results represent the maximum potential for medication cost reduction. Patients may be converted back to IV medications because their diet order changes. Our study took these re-conversions into consideration, as IV dose administrations were counted only when the patient was ordered a PO diet. Further limiting the potential savings is the fact that a provider may choose the IV form for a specific reason over the PO form such as use of IV pantoprazole in patients with a history of erosive esophagitis or IV voriconazole for invasive aspergillosis. However, it is highly unlikely that all of the patients concurrently ordered IV medication and PO intake were ineligible for IV to PO conversion of these 4 identified medications. Even a small increase in conversion when the patient is identified as clinically eligible would have a substantial impact due to the considerable difference in cost between the IV and PO forms. A limitation of our study is that generalizability from a budget impact analysis is complicated by many factors, including stability of case mix over time, comparability of cases, product prices, and medical practice patterns in an academic medical center to community practice in other institutions.15 Another limitation is the absence of data on PO dose administrations. We requested approval for IV medication doses only and thus were unable to analyze how frequently patients were switched between the different routes and how long any switch from IV to PO medication was delayed. Teich et al9 reported cost savings at Brigham and Women’s Hospital with a pharmacist-initiated alert for IV to PO medication conversion, when clinical indicators for PO medication intake, including PO diet and other PO medication orders, were present. This approach required an additional step of communication between a pharmacist and the physician in order to convert the medication route. Fischer et al10 initiated a follow-up study that targeted physicians directly by generating a reminder in CPOE at the time IV medication is prescribed when patients are receiving an oral
November 2011
diet or other oral medication. This study showed a statistically significant decrease in IV medication use and a corresponding increase in PO medication use. In a separate study, Galanter et al11 demonstrated overall compliance rates of 18.7% for a CPOE-generated alert suggesting conversion from IV to PO medication at the time medications are ordered. Although this study does not report the cost reduction associated with implementing this alert, this rate of compliance would reduce costs at our institution by tens, if not hundreds, of thousands of dollars each year for these 4 medications alone.
CONCLUSIONS Developing clinical decision support is time consuming and costly. Our findings, however, illustrate a need to develop a clinical alert within the CPOE system to remind providers to convert medications from IV to PO forms when established eligibility criteria for PO medication intake are met. When building clinical decision support to prompt providers to change medication route, developers must to take into consideration the potential benefit per interruption of an already busy clinician. Based on total cost alone, pantoprazole appeared to be a low-hanging fruit for future decision support. However, considering time, job satisfaction, and the cognitive cost of interrupting providers, developers may consider focusing on drugs with high savings per interruption, such as levetiracetam and chlorothiazide.
ACKNOWLEDGMENTS All authors contributed to, reviewed, and agree with the findings in this manuscript and report no financial conflicts of interest.
REFERENCES 1. Centers for Medicare and Medicaid Services. National Health Expenditures 2009 Highlights. https://www.cms. gov/NationalHealthExpendData/downloads/highlights. pdf. Accessed May 16, 2011. 2. Weber RJ. Core competencies in hospital pharmacy practice: department financial management. Hosp Pharm. 2006; 41:689 – 694. 3. ASHP guidelines on medication cost management strategies for hospitals and health systems. Am J Health Syst Pharm. 2008;65:1368 –1384. 4. Nadeau MC, Kuti EL. Clinical and economic impact of intravenous to oral conversion therapy programs. Conn Med. 2011;75:25–29.
1795
Clinical Therapeutics 5. Davis SL, Delgado JG, McKinnon PS. Pharmacoeconomic considerations associated with the use of intravenous-tooral moxifloxacin for community-acquired pneumonia. Clin Infect Dis. 2005; 41(Suppl 2):S136–143. 6. KagelEM,RayanGM.Intravenouscatheter complications in the hand and forearm. J Trauma. 2004;56:123–127. 7. Cunha BA. Oral versus IV treatment for catheter-relatedbloodstreaminfections. EmergInfectDis.2007;13:1800–1801. 8. Red Book: Pharmacy’s Fundamental Reference. New York, NY: Thomson Reuters, 2011. 9. Teich JM, Petronzio AM, Gerner JR, et al. An information system to promote intravenous-to-oral medication conversion. Proc AMIA Symp 1999:415– 419. 10. Fischer MA, Solomon DH, Teich JM, Avorn J. Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients. Arch Intern Med. 2003;163:2585–2589. 11. Galanter W, Liu XF, Lamber BL. Analysis of computer alerts suggesting oral medication use during computerized order entry of IV medications. Am J Health Syst Pharm. 2010; 67:1101–1105. 12. Glemaud I. Use of a physician order entry system to identify opportunities for intravenous to oral levofloxacin conversion. Am J Health Syst Pharm. 2000;57(Suppl 3):S14 –S16. 13. Kuti JL, Le TN, Nightingale CH, et al. Pharmacoeconomics of a pharmacist managed program for automatically converting levofloxacin route from IV to oral. Am J Health Syst Pharm. 2002;59:2209 –2215. 14. Przybylski KG, Rybak MJ, Martin PR, et al. Pharmacist-initiated program of intravenous to oral antibiotic conversion. Pharmacotherapy. 1997;17:271–276. 15. Mauskopf JA, Sullivan SD, Annemans L, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices— budget impact analysis. Value Health. 2007;10:336 –347.
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Address correspondence to: Brandyn D. Lau, SB, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument Street, Suite 8064, Baltimore, MD 21287. E-mail: [email protected]
Volume 33 Number 11