Use of a Deprescribing Tool in an Interdisciplinary Primary-Care Patient-Aligned Care Team

Objective: To pilot the VIONE approach in a single Primary Care Patient Aligned Care Team (PACT). The authors aim for the Clinical Pharmacy Specialist (CPS) to perform 20 comprehensive medication reviews (CMRs) and the pilot PACT physician (PCP) to complete 200 VIONE discontinuations. Cost avoidance and CPS recommendations will also be analyzed. Polypharmacy is associated with increased risk of adverse drug events, falls, hospitalizations, and death. VIONE is a deprescribing tool that assists providers in identifying inappropriate medications. Design: Quality Improvement Setting: Single VA Health Care System (VAHCS) Participants: High-risk veterans in pilot PACT Interventions: The CPS educated the PCP regarding VIONE methodology and assisted with CMRs. When deprescribing was warranted, VIONE discontinuation reasons were selected in the Computerized Patient Record System (CPRS). Data were electronically stored in a national dashboard. Results: The authors identified 231 veterans at risk for polypharmacy-related adverse events. The PCP and CPS were able to reach 99 veterans and make 136 medication discontinuations between September 1, 2019, and March 1, 2020. The CPS performed 20 CMRs, resulting in 90 deprescribing recommendations. Thirty-eight CPS recommendations were accepted and contributed $18,835.95 to the sum annualized cost avoidance of $21,904.80. Conclusion: The VIONE methodology was successfully implemented in the pilot PACT. The utilization of the CPS was associated with an increased average number of medication discontinuations per veteran and contributed to cost avoidance.

Smart SRUs Pre-Investment Utilizing Oxygen Enrichment Technology

This paper presents an unparalleled engineering assessment conducted to evaluate the feasibility of pre-investing in O2 enrichment technology, with the purpose of increasing the processing capacities of conventional air-based sulfur recovery units (SRUs). Ultimately, the goal is to minimize the overall number of required SRUs for a greenfield gas plant and, consequently, capture a significant cost-avoidance opportunity. The technology review revealed that a high-level O2 enrichment can double the processing capacity of air-based SRU, depending on the H2S content in acid gas. As H2S mole fraction in feed increases, the debottlenecking capability increases. For the project under assessment, the processing capacity of air-based SRUs showed a maximum increase of 80%. On the contrary, operating with high O2 levels, will elevate SRU reaction furnace temperature, and mandates installing high-intensity burners, along with special control and ESD functions, to manage potential risk and ensure safe operation. Additionally, the liquid handling section of SRUs (condensers, collection vessels, degassing vessels, sulfur storage tanks) should be enlarged to accommodate more sulfur production. Typically, the enriched oxygen can be supplied from air separation units (ASUs), which entails significant capital cost. Apart from these special design considerations, there are several advantages for adopting this technology. Oxygen enrichment removes significant nitrogen volumes, which reduces loads on Claus, tail gas treatment, and thermal oxidizer units. Hence, lower capital cost for new plants is acquired due to equipment size reduction. In addition, higher HP steam production and less fuel gas consumption are achieved. Conventionally, O2 enrichment technology is employed in the initial design stage or used to retrofit operating SRUs facilities. However, it is unique to consider O2 enrichment-design requirements as part of new air-based SRUs design for phased program development. The objective is to enable smooth transition to fully O2 enrichment operated SRUs at a later phase of the project without the need for any design modification. This exceptional pre-investment strategy has resulted into reducing the required number of SRUs at phase II from eight to five units; and accordingly, a significant cost avoidance was captured.

614. Evaluating the Use of Dalbavancin for Off-Label Indications

Background Dalbavancin (dalba) is a long-acting antibiotic (ABX) approved for skin and soft tissue infections. Post-marketing data suggests dalba is being used for off-label indications that require long term IV ABX; however, data assessing this off-label usage is limited. The purpose of this study was to evaluate the real-world efficacy, safety, and financial impact of off-label dalba use. Methods Setting: 4-hospital health system. Design: retrospective, observational study. Adult patients (pts) who received dalba from Jan 2018 to Jan 2021 for an off-label indication were included. Pts who were pregnant or had an infection caused by a pathogen outside dalba’s antimicrobial spectrum were excluded. Primary outcome was clinical success at 90 days defined as no need for additional ABX (excluding suppression therapy) or surgical intervention following dalba therapy and no positive cultures post treatment associated with the dalba-targeted infection. Secondary outcomes included safety (nephrotoxicity and hepatotoxicity). A financial analysis was performed by subtracting the cost of dalba from the anticipated cost of pt stay [&427/day for hospital; &262/day for skilled nursing facility (SNF)] if standard IV therapy was given. Results 50 pts met study criteria; 42% were IV drug users; 14% were self-pay. Indications included osteomyelitis (54%), endocarditis (22%), bacteremia (16%), and prosthetic joint infection (PJI) (8%). The predominant organism was S. aureus (60%), with 42% caused by MRSA. All but 1 pt received 1.5 g of dalba. 20 (40%) pts received 1 dose; 26 (52%) received 2. Overall, 43 (86%) pts achieved clinical success at 90 days, including 87% of osteomyelitis/PJI pts, 82% of endocarditis pts, and 100% of pts with bacteremia. There were no instances of nephrotoxicity or hepatotoxicity. Estimated cost avoidance per pt was &5210 and &1652 if traditional IV therapy was completed in the hospital and SNF, respectively. Because the alternative therapy to dalba could not be predicted, these costs were not included in analysis but likely would have increased calculated cost avoidance. Conclusion Dalba was associated with a relatively high success rate for the treatment of off-label indications and may have less total costs than traditional IV ABX. Disclosures James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose

1365. Clinical and Financial Implication of Dalbavancin Utilization on Length of Stay Avoidance in Acute Bacterial Skin and Skin Structure Infection

Background Our institution admits 650 patients annually for acute bacterial skin and skin structure infection (ABSSSI). These patients may require intravenous antibiotics, potentially complicated by social factors and loss to follow up. Dalbavancin is a long-acting lipoglycopeptide given as a single dose regimen for ABSSSI. A previous review conducted at our institution identified 117 potential avoidable hospital days over 4 months with outpatient dalbavancin use. The objective of this prospective study was to evaluate the clinical and financial impact of avoided admissions with outpatient dalbavancin use. Methods The Institutional Review Board approved this single-site, prospective study. All patients who presented to the emergency department (ED) with ABSSSI from December 15, 2020 to April 15, 2021 were included in the study. Dalbavancin eligibility criteria were given to providers. Eligible patients were given a single dose of dalbavancin and then discharged. The primary outcome was the difference between percentage of avoidable admissions from the ED with dalbavancin use in the retrospective cohort and prospective cohort. The secondary outcomes were estimated length of stay avoidance, percentage of treatment success without ED re-visit within 30 days, estimated hospital cost avoidance and drug cost reimbursement. The primary outcome was assessed using the Chi-square test. Descriptive statistics were used for the secondary outcomes. Results Fourteen patients received dalbavancin and avoided hospital admissions. The percentages of admissions avoided in the retrospective and prospective cohorts were 16.02% and 6.67%, respectively (Figure 1). A difference of 9.35% was found to be statistically significant (p=0.01). The total estimated length of stay avoidance was 50 days. No patients re-visited the ED within 30 days with treatment failure. The total estimated hospital cost avoidance was &148,852 (Table 1). The net reimbursement for dalbavancin over drug cost was &5,100 (Table 2). Conclusion Dalbavancin use decreased avoidable admissions. At our institution, annual hospital cost savings can reach &1,015,794 if dalbavancin was utlilized to all eligible patients. Disclosures All Authors: No reported disclosures

Evaluation of drug cost avoidance resulting from conduct of cancer clinical trials in a community-based oncology practice.

66 Background: Aim: To prospectively evaluate cost avoidance during routine conduct of cancer clinical trials in a community based integrated delivery network (IDN) consisting of a health services provider group, a health insurance plan and a hospital system. Only 2%–7% of adult cancer patients participate in clinical trials nationwide [1]. Inadequate funding and concerns about financial viability have been identified as factors that impede clinical trial accrual in the community oncology setting. ‘Cost-avoidance’, defined as dollars that would have been spent to purchase medications but were not spent because of study-related interventions [3] has been proposed as one mechanism to overcome this. Methods: Anti-cancer and hematology drugs provided by intergroup as well as pharmaceutical industry-based trial sponsors to patients enrolled in oncology clinical research were tabulated. Analysis of cost avoidance was restricted to patients covered by the IDNs health plan. Additionally, drugs provided by the trial sponsor were included in the analysis only if they represented a normal standard of care for the disease state. Cost avoidance was defined as the net ingredient cost of the drugs that would have been spent by the health plan for patient care if drugs provided by trial sponsors were not available. Results: Between January 2020 and April 2021, 25 patients covered by the IDN were recruited into clinical trials. Cost savings resulted from 7 targeted and immuno-oncology medications. Net cost avoidance in 2020 was $1,229,798 while that in 2021 till date has been $892,783. The realized cost savings has allowed recruitment of additional clinical research staff as well as expansion of clinical research to rural regional sites served by the IDN. Conclusions: Anticancer drugs provided free of charge by clinical trial sponsors render significant cost savings, ensuring viability and even expansion of oncology clinical research in community based IDNs. References: National Health Expenditure Data. 2018, U.S. Centers for Medicare & Medicaid Services: Baltimore, MD 21244. McDonagh MS, M.S., Naden E., Costs and savings of investigational drug services. American Journal of Health-Systems Pharmacy, 2000. 57: p. 40-43.[Table: see text]

Avoiding cost avoidance

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Firm Behavior in the Face of Severe Weather: Economic Analysis between Probabilistic and Deterministic Warnings

Tornadoes cause billions of dollars in damage and over 100 fatalities on average annually. Yet, an indirect cost to these storms is found in lost sales and/or lost productivity from responding to over 2000 warnings per year. This project responds to the Weather Research and Forecasting Innovation Act of 2017, H.R. 353, which calls for the use of social and behavioral science to study and improve storm warning systems. Our goal is to provide an analysis of cost avoidance that could accrue from a change to the warning paradigm, particularly to include probabilistic hazard information at storm scales. A survey of nearly 500 firms was conducted in and near the Dallas–Fort Worth metropolitan area asking questions about experience with tornadoes, sources of information for severe weather, expected cost of responding to tornado warnings, and how the firm would respond to either deterministic or probabilistic warnings. We find a dramatic change from deterministic warnings compared to the proposed probabilistic and that a probabilistic information system produces annual cost avoidance in a range of $2.3–$7.6 billion (U.S. dollars) compared to the current deterministic warning paradigm.

Proposed guidance on cost-avoidance studies in pharmacy practice

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. Summary Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists’ action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. Conclusions Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.