The cost of prescription drugs remains a primary focus across the healthcare spectrum from consumers, to regulators, to politicians, the media, and more. A wide range of legislative action is happening nationwide at both the state and local levels to improve the healthcare system for our patients including Mitigating Emergency Drug Shortages (MEDS) Act, ASHP advocacy to defend federal 340b programs, and the enactment of pharmacist provider status nationwide. All have significant budgetary impacts.
Drug spend is high and continuing to rise
Since 2013, rising drug prices, in addition to ongoing shortages, have placed a strain on hospitals’ budgets and operations. Inpatient hospital prescription drug spending has consistently increased by approximately 15 to 20% over the past 7 years. In fact, more than 66% of hospitals surveyed by the American Hospital Association reported that changes in drug prices had a moderate to severe impact on their ability to manage hospital budgets. Key areas causing the greatest impact on increased hospital pharmacy budgets are new FDA approvals, medication shortages, and specialty therapies.
Inpatient pharmacy is a unique department, with 80% of its overall costs derived from drug spending. Strategizing to maintain the most appropriate use of medications is key, and pharmacy teams are essential to making an impact. Here, we will review the impact pharmacy teams can make, focusing on key clinical focus areas that produce the greatest amount of return and/or cost savings for most facilities.
Clinical pharmacy impacts bottom line and patient outcomes
During the early 1990s, the impact of clinical pharmacist services on healthcare outcomes in hospitalized patients was studied at Walter Reed Army Medical Center. Medical and surgical teams were examined to compare cost savings contributing to the care of over three thousand patients. They concluded that healthcare teams with pharmacists produced a shorter length of stay, lower drug cost per admission, with minimal impact to mortality. The average cost savings was approximately $400 per inpatient admission, with a benefit-to-cost ratio of 6.03:1.
The practice of clinical pharmacy has evolved since that time, with an increase of value-added services being provided by pharmacists in practice areas ranging from pediatrics to outpatient ambulatory. So where are some areas where we’re seeing the greatest opportunity for pharmacists to impact? Here we’ll explore key opportunities in Antimicrobial Stewardship (AMS) and Critical Care.
ASP Case Study: Aultman Hospital improves antimicrobial stewardship, patient care and drives $2 million in savings
Antimicrobial stewardship cost containment
Optimizing the use of antimicrobial therapy is critical to effectively treat infections, protect patients from harm caused by unnecessary antibiotic use, and to combat antibiotic resistance. Strategies for AMS cost containment include consistent use of IV to oral conversion, de-escalation, discontinuation, therapeutic interchanges, dose optimization, and enforcing those restricted high-cost antibiotics.
Dose optimization, with a method such as extended infusion (EI) beta lactam therapy, may improve clinical survival rates of critically ill patients with resistant gram-negative infections. Literature also finds evidence that this method results in decreased overall costs and decreased length of stay. According to one study at a 651-bed hospital, EI piperacillin tazobactam produced a significant reduction in cost, with a potential savings in the range of $68,750- $137,500 annually.
Sanford USD Medical Center reported a cost savings of approximately $388K over a twenty- four-month period, after adjusting protocols to administer piperacillin- tazobactam over 4 hours vs. the standard 30-minute infusion. Studies indicate the greatest success using this method with piperacillin tazobactam, meropenem, and cefepime. We’re currently seeing this with our customers where pharmacists are using Sentri7 to identify patients that may qualify for this cost savings dose optimization. Having this information in real time decreases the amount of time a patient may spend on a regimen that may be less than optimal. Consistent patient surveillance also decreases pharmacy waste and saves nursing administration time.
IV to oral conversion
IV to Oral conversion is another area that’s key to optimizing antimicrobial therapy and used to contain costs. A large pediatric health system was challenged with strengthening the connection between the system’s patient safety goals and the pharmacy's contribution to those goals, while demonstrating cost savings. They initially focused on antimicrobial stewardship using Sentri7’s evidence-based library to establish a set of rules and metrics. After one year, they reduced their total vancomycin use by 30%, increased pharmacist dose evaluations during rounding by over 100%, and had over a 300% increase in IV to oral conversions. These efforts lead to overall cost savings of $1.2M in hard cost savings.
Critical care cost containment
The critical care environment is another area where the impact of the clinical pharmacist has been demonstrated for years. In an analysis to evaluate the pharmacist impact on patient care outcomes and cost savings over a two-year trial period, clinicians were given an expanded prescribing authority within a 700-bed hospital in the Neurotrauma ICU within a community health system. The expanded scope of practice enabled the pharmacists to initiate, modify, and or discontinue, as well as order, permanent lab tests. This allowed them to have a more comprehensive therapeutic optimization of patients’ medication therapy. The result was a 182% increase in therapeutic optimization, nearly an 80% reduction in preventable adverse drug events, as well as a $2 million increase in cost savings.
Utilizing clinical pharmacists across inpatient settings
More recently, hospital pharmacy revenues have declined sharply as result of the COVID-19 pandemic. It will be even more vital that pharmacy demonstrates its vigilance in the area of cost containment, while providing excellent pharmacotherapeutic consultative services. Within hospitals experiencing a reduction of surgical, oncology, and ambulatory services, it’s paramount that those highly qualified clinicians are reassigned to cross cover in other inpatient areas requiring pharmacist supervision. Critical care pharmacists with training in intensive care and emergency medicine may be called upon to expand their services as the patient volume of critically ill patient rises.
With an expected shortage of medications, and the rapidly changing landscape of drug therapy for SARS-CoV-2 patients, consistent communication between the medical and nursing staff is pivotal to ensure favorable outcomes. Utilizing pharmacists during rounds to provide therapeutic recommendations of appropriate therapy, while communicating with pharmacy operations, promotes conservation of available antibiotics, vasopressors, sedatives, neuromuscular blockers, and opiates. Additionally, this provides an opportunity to leverage technology using real-time clinical surveillance for these efforts. Clinicians can use clinical surveillance technology, such as Sentri7, to monitor the rapidly changing status of patients and enhance efforts of inventory management.
Utilizing pharmacy value-added services
Finally, the consistent application of foundational clinical pharmacy value-added services proves to significantly save costs over time. Many facilities use pharmacy extenders such as students, interns and residents to aid in the provision of services. The addition of focused, consistent efforts in clinical services with operational improvements can lead to significant savings within a system. Operational efforts such as dose rounding, batch dosing, and GPO contract negotiations have proven to be effective tools.
It’s also prudent that we have focused efforts directed towards early identification of opportunities for cost savings by leveraging technology and applying these efforts during all staffing hours. Not only should we use technology to identify these patients, but also to track trends and to recognize areas for improvement.
As hospitals continue to face margin pressures and forecasts paint a dire picture of the U.S. healthcare system’s financial future, forward-thinking hospitals are depending upon the expertise of pharmacy teams to help improve hospital performance by focusing on medication use and cost containment. It’s evident that clinical pharmacists can make deep impacts in these areas and improve patient outcomes. With a continued focus here, our patients will become safer and our processes will become more streamlined — ensuring the utmost in quality care.