Use of clinical decision support to identify i.v.-to-oral conversion opportunities and cost savings

Carver, Kenneth H.; Burgess, L. Hayley; Cooper, Mandelin; Elders, Ty; Kramer, Joan

doi:10.2146/ajhp170405

Cited by 7 publications

(5 citation statements)

References 10 publications

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“…Previous studies have shown that IV to PO conversion programs can increase PO utilization and reduce drug costs [4][5][6][7][8][9][10]. Our study results highlight the positive impact that the revision of an ASP program's pre-existing IV to PO conversion criteria and protocol can have to decrease IV medication utilization rates and increase PO utilization, resulting in overall decreased costs.…”

Section: Discussionsupporting

confidence: 51%

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System

et al. 2023

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The CDC’s Core Elements of an Antimicrobial Stewardship Program (ASP) lists intravenous (IV) to oral (PO) conversion as an important pharmacy-based intervention. However, despite the existence of a pharmacist-driven IV to PO conversion protocol, conversion rates within our healthcare system remained low. We aimed to evaluate the impact of a revision to the current conversion protocol on conversion rates, using linezolid as a marker due to its high PO bioavailability and high IV cost. This retrospective, observational study was conducted within a healthcare system composed of five adult acute care facilities. The conversion eligibility criteria were evaluated and revised on 30 November 2021. The pre-intervention period started February 2021 and ended November 2021. The post-intervention period was December 2021 to March 2022. The primary objective of this study was to establish if there was a difference in PO linezolid utilization reported as days of therapy per 1000 days present (DOT/1000 DP) between the pre- and post-intervention periods. IV linezolid utilization and cost savings were investigated as secondary objectives. The average DOT/1000 DP for IV linezolid decreased from 52.1 to 35.4 in the pre- and post-intervention periods, respectively (p < 0.01). Inversely, the average DOT/1000 DP for PO linezolid increased from 38.9 in the pre-intervention to 58.8 for the post-intervention period, p < 0.01. This mirrored an increase in the average percentage of PO use from 42.9 to 62.4% for the pre- and post-intervention periods, respectively (p < 0.01). A system-wide cost savings analysis showed projected total annual cost savings of USD 85,096.09 for the system, with monthly post-intervention savings of USD 7091.34. The pre-intervention average monthly spend on IV linezolid at the academic flagship hospital was USD 17,008.10, which decreased to USD 11,623.57 post-intervention; a 32% reduction. PO linezolid spend pre-intervention was USD 664.97 and increased to USD 965.20 post-intervention. The average monthly spend on IV linezolid for the four non-academic hospitals was USD 946.36 pre-intervention, which decreased to USD 348.99 post-intervention; a 63.1% reduction (p < 0.01). Simultaneously, the average monthly spend for PO linezolid was USD 45.66 pre-intervention and increased to USD 71.19 post-intervention (p = 0.03) This study shows the significant impact that an ASP intervention had on IV to PO conversion rates and subsequent spend. By revising criteria for IV to PO conversion, tracking and reporting results, and educating pharmacists, this led to significantly more PO linezolid use and reduced the overall cost in a large healthcare system.

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Section: Discussionsupporting

confidence: 51%

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System

et al. 2023

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“…Most studies (n = 50) reported on interventions that used more than 1 approach to optimize ePrescribing systems (Table 3). 4,41–94 Table 3 summarizes the various combinations of optimization strategies and intervention components that were used in the included studies and the overall reported effectiveness of the intervention on the primary outcome.…”

Section: Resultsmentioning

confidence: 99%

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

et al. 2022

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Objective: Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures.Methods: We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts.Results: We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process.Discussion: We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

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“…The commercially available clinical surveillance software used by the health system was external and separate from the electronic health record (EHR) system. The software aligned data with a library of >3,000 algorithms ("rules"; Carver et al, 2018) and served as the primary software pharmacists used in their daily workflow. If rule requirements were satisfied, the software created an alert.…”

Section: Preimplementation Clinical Pharmacist Workflow Alert Managementmentioning

confidence: 99%

“…For these reasons, some health systems use clinical surveillance software to notify pharmacists of clinical opportunities to maximize workflow efficiency, thereby increasing the number of interventions completed per patient (Calloway et al, 2013). Clinical surveillance software notifies pharmacists of possible adverse drug events (ADEs), intravenous (IV)-to-oral-medication conversion opportunities, renal dose adjustment opportunities, culture surveillance updates, extended duration of antibiotic therapy, and duplicate therapy interventions (Calloway et al, 2013; Carver et al, 2018; Hamblin et al, 2012; Huber et al, 2016; Jha et al, 2008; Kawamoto et al, 2005; Rech, Adams, et al, 2021; Rech, Gurnani, et al, 2021). Optimized pharmacist workflows that result in completed interventions reduce adverse events, increase cost savings, and improve patient outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…A meta-analysis reported that 68% of studies ( n = 70) found a significant improvement in clinical practice with the use of clinical support systems (Kawamoto et al, 2005). The use of clinical decision support to identify IV-to-oral medication conversion saved hospitals 9% on medication costs, and if completed in a timelier manner could lead to an additional 29%–78% in cost savings while improving patient safety (Carver et al, 2018). The potential to increase intervention timeliness and cost savings led to a clinical pharmacy workflow optimization project for 169 hospitals of varying sizes across a large for-profit health system with well-established clinical pharmacy surveillance software integrated into the clinical pharmacist workflow.…”

Section: Introductionmentioning

confidence: 99%

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Impact of Clinical Pharmacy Surveillance on Pharmacy Services: A Quality Improvement Project

Kramer,

Borum,

Claxon

et al. 2023

Journal of Healthcare Management

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Goal: The purpose of this quality improvement project was to retrospectively evaluate pharmacist time to clinical surveillance alert intervention before and after implementing a pharmacy-directed alert priority category across a large for-profit United States health system with well-established clinical pharmacy surveillance software integrated into the clinical pharmacy workflow. The findings contributed to a financial evaluation of pharmacist productivity compared with drug spend for pharmacy-directed interventions that included intravenous (IV)-to-oral-conversion and renal dosing opportunities. Methods: A retrospective quality improvement pre-/postanalysis of deidentified, prepopulated clinical surveillance alert data for the preimplementation period of January 1, 2021, through September 30, 2021, was compared with that for the postimplementation period of November 1, 2021, to January 31, 2022, for 169 hospitals. Clinical pharmacist workflow was mapped pre- and postimplementation. The average time to alert intervention was calculated using the mean time in minutes between the alert firing within the software and when the pharmacist reviewed the alert, grouped by hospital, alert status, and priority category. Medications converted from IV to oral were assessed using the clinical surveillance software IV-to-oral calculator. Postimplementation renal dose cost savings were modeled using pharmacist-completed alerts by rule name that indicated a possible dose decrease based on the patient's renal function and current medication. Principal Findings: Time to alert intervention for all completed pharmacist interventions was reduced for high-priority alerts by 32.6 min (p < .001) and routine-priority alerts by 65.1 min (p = .147). Alerts that moved to the pharmacy-directed alert priority category resulted in a reduced time to alert intervention of 38.7 min (p = .003). Normalized average wholesale price (AWP) cost savings from IV-to-oral conversion within 3 days of conversion eligibility were $1,693,600 in the preimplementation period and $1,867,400 in the postimplementation period, a $173,700 increase in cost savings. A total of 7,972 completed postimplementation renal dose adjustments resulted in a modeled AWP normalized cost savings of $1,076,700. Practical Applications: Results indicated that optimizing clinical surveillance software alerts was effective and increased pharmacist productivity. Specifically, creating a pharmacy-directed alert category that pharmacists were able to complete by hospital policy or protocol improved workflow efficiency and increased IV-to-oral medication conversion cost savings. Further study is needed to validate the renal dose–modeled cost savings and address the financial benefits of quality measures to prevent acute kidney injury.

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Use of clinical decision support to identify i.v.-to-oral conversion opportunities and cost savings

Abstract: Hospital pharmacists' i.v.-to-oral conversion practices with the CDS tool resulted in medication cost savings of 9%, or $1.48 million, for 13 medications evaluated over a 6-month period.

Cited by 7 publications

References 10 publications

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

Impact of Clinical Pharmacy Surveillance on Pharmacy Services: A Quality Improvement Project

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