scholarly journals Decreasing Inappropriate Use of Rasburicase to Promote Cost-Effective Care

2019 ◽  
Vol 15 (2) ◽  
pp. e178-e186 ◽  
Author(s):  
Komal K. Patel ◽  
Timothy J. Brown ◽  
Arjun Gupta ◽  
Taylor Roberts ◽  
Eileen Marley ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Tumor Lysis Syndrome ◽  
Cost Effective ◽  
Baseline Period ◽  
Study Phase ◽  
Hospital System ◽  
Tumor Lysis ◽  
Inappropriate Use ◽  
Recommended Treatment ◽  
Effective Care

BACKGROUND: Rasburicase is a recommended treatment of tumor lysis syndrome and patients at high-risk for developing tumor lysis syndrome. Unfortunately, it is expensive, and unnecessary use raises costs of care. METHODS: Plan, Do, Study, Act methodology was used to decrease the inappropriate use of rasburicase. In the Plan phase, a multidisciplinary quality improvement team reviewed the rasburicase ordering process and its prescription patterns at Parkland Health and Hospital System between October 2015 and September 2017 to determine appropriate interventions for improvement. In the Do phase, interventions were deployed to improve rasburicase prescriptions. In the Study phase, the team reviewed the rasburicase orders and appropriateness from February 2018 to October 2018. During the Act phase, the interventions were found to be successful, and the process changes were solidified. RESULTS: At baseline, 65 doses of rasburicase were administered during the 2-year baseline period, 21 of these (32.3%) were inappropriate. Review of the ordering process identified pitfalls: one-click ready-to-sign order, fixed default dose, no hard-stop alert requiring physicians to review and confirm appropriate indications, and lack of secondary pharmacy review. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In February 2018, we implemented the interventions, which resulted in reduction in inappropriate rasburicase use, with only a single inappropriate order placed in 7 months postintervention. CONCLUSION: A multidisciplinary approach and classic quality improvement methodology enabled us to reduce inappropriate rasburicase use. Straightforward electronic medical record interventions and secondary pharmacy review are effective in addressing overuse.

Reducing inappropriate rasburicase use to promote cost-effective care.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 312-312
Author(s):  
Arjun Gupta ◽  
Komal Patel ◽  
Taylor Roberts ◽  
Eileen M. Marley ◽  
Hsiao Ching Li ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Best Practice ◽  
Tumor Lysis Syndrome ◽  
Kidney Injury ◽  
Cost Savings ◽  
Cost Effective ◽  
Baseline Period ◽  
Hospital System ◽  
Effective Interventions ◽  
Quality Improvement Interventions

312 Background: Rasburicase is recommended for treating established Tumor lysis syndrome (TLS) and patients at high-risk for TLS. Unfortunately, it is an expensive medication and unnecessary use contributes to expenses. Methods: A multidisciplinary quality improvement team reviewed the process of ordering rasburicase and its prescription patterns at Parkland Heath and Hospital System, Dallas, TX between 10/2015-9/2017. Use was determined as appropriate/ inappropriate based on internally approved indications (laboratory TLS, at-risk for TLS, acute kidney injury and hyperuricemia, failure of or inability to administer allopurinol). Quality improvement interventions were implemented based on weaknesses identified. Results: 65 doses of rasburicase were administered during the 2-year baseline period; 21 (32.3%) of these were grossly inappropriate. The most common ordering providers were oncologists (23 orders, 35%), hospitalists (16 orders, 25%), intensivists (11 orders, 17%), and emergency physicians (8 orders, 12%). Ordering process review identified several pitfalls: one-click ready to sign order, auto-population of dosage, no hard-stop requiring providers to review rasburicase indications, and no pharmacy oversight. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In 2/2018, we implemented PDSA cycle 1 including introducing a best practice advisory requiring providers to select an approved indication for medication use and changed auto-population of rasburicase dosage to 3 mg. A mandatory secondary review by pharmacy prior to dispensing the medication was implemented. Over a 3-month period post-change (2/2018- 5/2018), 11 of 11 rasburicase administered doses have been appropriate (0% inappropriate). Conclusions: A multidisciplinary team and classic quality improvement methodology was able to reduce inappropriate rasburicase use from 32.3% to 0%, with significant cost savings. Straightforward electronic medical record interventions and increased pharmacy oversight are effective interventions in curbing medication overuse. We will periodically re-assess utilization patterns and refine PDSA cycles as needed.

Assessment of Cost-Effective Antibiotic Therapy in the Management of Infections in Cancer Patients

1994 ◽  
Vol 28 (1) ◽  
pp. 105-111 ◽  
Author(s):  
Michael A. Cimino ◽  
Coleman M. Rotstein ◽  
Jason E. Moser
Keyword(s):  
Quality Improvement ◽  
Antibiotic Therapy ◽  
Clinical Pharmacist ◽  
Hospital Setting ◽  
Cost Savings ◽  
Cost Effective ◽  
Baseline Period ◽  
Economic Benefits ◽  
Consensus Approach ◽  
Quality Improvement Effort

OBJECTIVE: To describe the economic benefits of a quality improvement effort directed at optimizing clinical outcome. DESIGN: A before—after observational design was used to evaluate the cost-effectiveness of a consensus approach to antimicrobial therapy. SETTING: The evaluation was conducted at a cancer research hospital. PATIENTS: Oncology patients requiring parenteral antibiotic therapy were consecutively observed. MAIN OUTCOME MEASURES: Outcome (clinical and microbiologic response), safety, and cost of therapy were assessed during a baseline period and compared to a period during which the consensus approach was used. INTERVENTIONS: The influence of a designated individual, in this case a clinical pharmacist, responsible for promotion of the consensus approach was explored. RESULTS: The consensus approach in combination with the promotional efforts of the clinical pharmacist was associated with a 13 percent increase in overall clinical response and a reduction of pathogen persistence from 22 to 11 percent. No difference in the average number of adverse effects per patient was observed over the two observation periods. These findings were associated with an estimated $22000/month cost savings. The consensus approach alone, without benefit of the clinical pharmacist, was not associated with improved therapeutic outcome or cost savings over the same observation periods. CONCLUSIONS: These data suggest that a consensus approach to antibiotic therapy can be cost-effective. An individual, such as a clinical pharmacist, may add significantly to quality improvement and cost-effective efforts in a hospital setting.

Costs and Outcomes Associated with Rasburicase Versus Allopurinol in Patients with Tumor Lysis Syndrome.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3175-3175
Author(s):  
Mitchell S. Cairo ◽  
Stephen Thompson ◽  
Krishna Tangirala ◽  
Michael T. Eaddy
Keyword(s):  
Retrospective Study ◽  
Length Of Stay ◽  
Administrative Data ◽  
Tumor Lysis Syndrome ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Cancer Type ◽  
Tumor Lysis ◽  
Urine Alkalinization ◽  
High Level

Abstract Abstract 3175 Background: Tumor lysis syndrome (TLS) is an oncologic emergency resulting in several metabolic abnormalities (Cairo et al, BJH, 2004). Hyperuricemia and its associated complications are the most frequent manifestations of TLS. For decades, treatment has consisted of hydration, urine alkalinization, and administration of allopurinol (Cairo et al BJH, 2011). However, recent clinical trials have shown that initiation of rasburicase, a hypouricemic agent, within four hours significantly reduces high uric acid (UA) levels in patients experiencing TLS (Goldman et al Blood, 2001). Studies demonstrate that rasburicase is safe and effective, has excellent tolerability, and is potentially cost-effective in patients at high risk for TLS. Objective: The objective of this retrospective analysis was to evaluate real-world differences in UA levels, length of stay and costs for patients initiating treatment with rasburicase compared to patients receiving allopurinol. Methods: A retrospective study, spanning January 1, 2005 to March 31, 2009, was conducted utilizing administrative data from more than 400 U.S. hospitals. Hospitalized patients with clinically confirmed TLS, who received rasburicase or allopurinol during the study period were eligible for inclusion. Patients with a diagnosis of gout, as determined by the presence of an ICD-9 diagnosis code 274.x, were excluded from the study. Patients receiving rasburicase were propensity score matched to allopurinol-treated patients in a 1:4 ratio based on time between hospital admission and treatment initiation, baseline UA level, cancer type, age, gender, race, hospital characteristics, payer type, and prior intensive-care unit (ICU) admission. Differences in length of stay (LOS), changes in UA levels and serum creatinine, days in the ICU, and costs per percent of UA reduction were assessed through various statistical models. Due to a high level of missing cancer diagnosis, comparative results of rasburicase and allopurinol were also evaluated through sensitivity analysis to test the robustness of the results. Results: A total of 130 patients were identified, matched and included in this study; 26 initiated treatment with rasburicase and 104 were treated with allopurinol. Patients were predominately male (∼61%) Caucasian (∼76%) with an average age of 55 years. There were no statistically significant differences among baseline variables between the two cohorts. Prior to initiating treatment, mean UA levels were 11.4 mg/dL for the rasburicase cohort and 11.2 mg/dL for allopurinol cohort. By the second day of treatment mean UA levels were 5.3 mg/dL (p<0.0001) lower for rasburicase (2.7mg/dL) compared to allopurinol (8.0 mg/dL). Changes in potassium, phosphorus and creatinine levels were not statistically different across the two cohorts. The LOS for patients in the rasburicase cohort averaged 11.5 days compared to 16.5 days for allopurinol patients (p=0.0212); rasburicase patients also had a lower ICU LOS, 1.4 and 3.9 days, respectively (p<0.0001). The reduction in LOS correlated with a reduction in costs, which averaged $34,065 per rasburicase patient compared to $54,103 per allopurinol patient (p=0.0205). Results of the sensitivity analyses did not change the overall findings. Conclusions: This retrospective study, using hospital administrative data, revealed that treatment with rasburicase, compared with allopurinol, was associated with a significant reduction in UA levels, ICU LOS, overall LOS and overall costs per patient. Despite the increase pharmaceutical costs of rasburicase versus allopurinol, the use of rasburicase in patients with TLS is cost effective and reduces LOS. Disclosures: Cairo: sanofi aventis: Consultancy. Thompson:sanofi aventis: Employment. Tangirala:sanofi aventis: Employment. Eaddy:Xcenda: Employment.

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