Researchers find huge savings opportunity in oral form of IV drugs
Education, decision support can drive change
Hospitals could potentially save millions of dollars by swapping commonly prescribed intravenous (IV) medications with their oral equivalents in patients who can safely take medications by mouth, according to a new study by researchers at Johns Hopkins Hospital in Baltimore, MD. The research, which was published in the journal Clinical Therapeutics, involved a review of the hospital's computerized physician-order entry system for the year 2010 from the hospital's Department of Medicine, not including surgical patients.1
The researchers looked at the financial implications of switching out just four commonly prescribed IV medications: chlorothiazide, a drug used to treat blood pressure and fluid retention; voriconazole, an anti-fungal medication; levetiracetam, which is used to treat seizures; and pantoprazole, a treatment for acid reflux. They concluded that the hospital could have saved more than a million dollars by utilizing the oral equivalents of the IV drugs in cases where patients were either prescribed some of their medications orally or they were being fed by mouth. And that's just a portion of the potential savings, according to the researchers.
"We only looked at the cost of buying the drugs. We did not look at the cost of starting an IV and maintaining an IV, and we didn't look at the cost of having a [case] of sepsis," explains Christoph Lehmann, MD, a co-author of the study and the director of Clinical Information Technology at Johns Hopkins Children's Center in Baltimore, MD. Furthermore, Lehmann emphasizes that there are many other IV drugs that can be given in oral form, and the oral equivalents are generally much less expensive than the IV medications.
In fact, the differences in cost are eye-popping. For example, the researchers report that the wholesale price of a 5-milligram tablet of chlorothiazide is $1.48, and the equivalent dose of the drug in IV form is $357. Similarly, pantoprazole, which was the most commonly prescribed drug in the study, costs about $4 for a 40-milligram tablet, and $144 for the same dose in IV form.
Other studies have looked at this issue, but they have primarily focused on antibiotics, because these drugs are so widely prescribed in the hospital setting, explains Brandyn Lau, a co-author of the study and a medical informatics specialist at Johns Hopkins University School of Medicine. "What we tried to do is look at four different classes of drugs to try to give better generalizability hospital-wide," he says. With broader application, the savings would be enormous, says Lau.
Make use of prompts for busy clinicians
With both safety and savings on the line, it seems as though switching an order for an IV drug to its oral equivalent would be an easy, straight-forward decision for physicians, but that is not the case, explains Lehmann. "I am an intensivist who works in a newborn intensive-care unit," he says, explaining that his number one priority is to keep his young patients "away from the abyss." Decisions about whether it is time to pull out a central line are crowded out by more urgent matters, adds Lehmann. "I counted once. By 11 o'clock in the morning, I had been asked 50 questions that I had to make decisions about ... so my capacity for thinking about these things, keeping those balls in the air, and actually moving on such issues is limited, and that is probably true for most physicians."
Furthermore, while there are opportunities for savings in every hospital department, there are often added challenges in the emergency setting. "ED physicians deal with great degrees of uncertainty," says Lehmann. "A patient walks in and complains of a stomachache. That could be an aortic aneurysm, and that patient might need to be in the operating room in the next hour, so the treating physician is not going to let that patient have a diet."
Given the pressures and distractions that all hospital physicians deal with, Lehmann believes hospitals should consider developing clinical decision support tools to help prompt physicians when an opportunity to switch a patient from IV meds to the oral equivalents presents itself. In fact, one of the key reasons he delved into this research was because he wanted to make a strong case for the value of clinical-decision support tools.
"I believe that using health information technology to help prompt doctors to do the right thing will improve quality and safety, and it will make care better and it will make patients happier," says Lehmann. But he acknowledges that off-the-shelf software does not come equipped with this type of clinical-decision support, and such tools are expensive to build. But Lehmann believes this type of clinical-decision support can not only boost quality, but also ultimately save money.
Take a generalized approach
In developing any such tool, however, Lehmann emphasizes that designers need to insure that physicians are not bombarded with alerts. "Every time I am in the middle of rounds and something pops up and tells me that I am supposed to do something, I lose my train of thought. There is a potential for error, so it comes at a cost in itself," he says.
Consequently, Lehmann advocates for a more generic type of approach that would, for example, notify a physician when a patient is receiving 80% to 90% of his or her intake by mouth, and yet still is receiving medication via IV. This type of generalized alert would be triggered when the patient reaches a certain oral-intake threshold. It would list the IV medications the patient is on that have oral equivalents, and suggest that the physician consider switching the patient over to the oral drugs, explains Lehmann. "This would be the most convenient and least interruptive [approach]," he says. "And it would be most effective because you would target a large number of medications at the same time."
With this type of clinical-decision support mechanism, there will be times when physicians decide a patient is too sick to receive the oral medications, or there may be other reasons why the patient may be better served by the IV medication, says Lehmann, but he stresses that at least physicians will have good information at hand to make the best decisions for patient care.
Physician education around this issue can also be effective, says Lehmann. Clinicians need to be aware that oral medications are much less expensive than the same drugs in IV form, he says. With this information, they might be inclined to change their prescribing patterns even without constant reminders, he adds.
Consider the financial impact
With the considerable savings that are possible from reducing the amount of IV medications that are used, you would think that payers would be demanding the kinds of changes suggested in this study. However, Lehmann points out that it is generally the hospitals that are on the hook for these IV medication charges because most payers pay a flat fee for a hospital stay as long as there is no change in length of stay.
And indeed, Lehmann reports that administrators at Johns Hopkins are intrigued by the study's findings, and interested in taking the next step. Consequently, as soon as resources are allocated, researchers plan to build this type of clinical-decision support tool so that it can be implemented and studied further. Lehman believes it will take at least six months to develop this tool, but he is also eager to leverage clinical-decision support in additional ways.
"We all know that this is where we are going to have an impact on patient care, so being able to tie [this tool] with savings is something that will allow me to do the other really cool things that are possible with clinical decision support," he says.
- Lau B, Pinto B, Thiemann D, et al. Budget impact analysis of conversion from intravenous to oral medication when clinically eligible for oral intake. DOI:10.1016/jclinthera.2011.09.030.