Leveraging drug-utilization and external benchmarking data to drive change in prescribing behaviors.

PURPOSE: Improved outcomes and cost savings achieved at a large hospital through a drug utilization benchmarking and reporting initiative are described. SUMMARY: Using the University HealthSystem Consortium (UHC) Clinical Resource Manager (CRM) database, the University of Kansas Hospital identified nine target areas (based on Medicare Severity Diagnosis-Related Group) in which the hospital's drug-utilization practices were deemed suboptimal relative to those of other UHC member facilities with similar caseloads. The pharmacy department developed a CRM template for generating customized reports comparing the hospital's performance on various drug-utilization metrics with that of top-performing peers (i.e., institutions achieving the best patient care outcomes in terms of mortality and length of stay) in the nine target areas. A pre-post comparison of drug-utilization data collected before and after implementation of the reporting initiative indicated improved outcomes in all nine initially selected target areas, with estimated cumulative annualized cost savings of about $900,000. The CRM-generated reports are now distributed semiannually to attending physicians and other hospital leaders via electronic and hard-copy means, focusing on variances from UHC top-performer and overall UHC averages in the use of higher-cost drugs. The reporting initiative has generally fostered enhanced physician-pharmacist collaboration in the investigation of identified drug-utilization variances and implementation of practice changes. CONCLUSION: By evaluating service-specific trends of internal drug utilization against external benchmarks and emulating prescribing practices at top-performing institutions, an academic medical center has achieved improved patient care outcomes and cost savings.

Clostridium difficile-positive stools: a retrospective identification of risk factors.

In an attempt to determine the association of potential risk factors and an increase in the rate of Clostridium difficile-associated diarrhea (CDAD) at a tertiary teaching institution in the Midwest United States, all CDAD cases among admissions from a period of 20 consecutive months were analyzed. A retrospective chart review was performed on 4992 admissions from this period. Logistic regression analysis suggested a correlation between CDAD and multiple factors.

Acute renal failure associated with inhaled tobramycin.

PURPOSE: A case of nephrotoxicity possibly caused by tobramycin inhalation solution is presented. SUMMARY: A 62-year-old Caucasian woman was admitted for treatment of decreased urine output and sepsis secondary to Pseudomonas aeruginosa. Her past medical history was significant for multiple diseases, including chronic renal insufficiency (baseline serum creatinine concentration [SCr] 2 mg/dL). One month postadmission, the patient was diagnosed with health care-associated pneumonia. The patient was initiated on piperacillin-tazobactam and tobramycin 2 mg/kg i.v. She was changed to imipenem-cilastatin with continuation of i.v. tobramycin. A month after discontinuation of her antibiotic regimen, the patient was diagnosed with P. aeruginosa pneumonia. The patient received imipenem-cilastatin, vancomycin, and inhaled tobramycin 300 mg twice daily. At that time, her SCr was 2 mg/dL. Inhaled tobramycin was continued for four weeks, and the patient's SCr steadily rose to a peak of 4.5 mg/dL. During week 1 of treatment, multidrug-resistant P. aeruginosa and methicillin-resistant Staphylococcus aureus were diagnosed. The patient continued to receive i.v. imipenem-cilastatin, vancomycin, and inhaled tobramycin with an SCr of 1.9 mg/dL. However, at the end of week 2, the patient's SCr began to slowly rise (2.3 mg/dL). At week 3, imipenem-cilastatin was discontinued; inhaled tobramycin was continued. The patient's SCr continued to rise (3.2 mg/dL). At week 4, her SCr rose to 4.5 mg/dL, resulting in initiation of hemodialysis and discontinuation of inhaled tobramycin. The patient's SCr never returned to baseline, and renal function was never regained. CONCLUSION: Acute renal failure requiring dialysis occurred in a high-risk patient receiving an extended course of treatment with inhaled tobramycin.

Medication-related problems in ambulatory hemodialysis patients: a pooled analysis.

BACKGROUND: Medication-related problems are common in hemodialysis (HD) patients. These patients often require 12 medications to treat 5 to 6 comorbid conditions. Medication-related problem research reports cannot be generalized to the entire HD population because data are obtained from single centers and limited numbers of patients. We conducted a pooled analysis to gain additional insight into the frequency, type, and severity of medication-related problems and extrapolated the data to the entire US HD population. METHODS: Articles were identified through a MEDLINE search (1962 to March 2004). Seven studies were included in the analysis. Medication-related problems were categorized into the following 9 categories: indication without drug therapy, drug without indication, improper drug selection, subtherapeutic dosage, overdosage, adverse drug reaction, drug interaction, failure to receive drug, and inappropriate laboratory monitoring. A medication-related problem appearance rate was determined. RESULTS: We identified 1,593 medication-related problems in 395 patients (51.2% men; age, 52.4 +/- 8.2 years; 42.7% with diabetes). The most common medication-related problems found were inappropriate laboratory monitoring (23.5%) and indication without drug therapy (16.9%). Dosing errors accounted for 20.4% of medication-related problems (subtherapeutic dosage, 11.2%; overdosage, 9.2%). The medication-related problem appearance rate was 5.75e(-0.37x), where x equals number of months of follow-up (P = 0.02). CONCLUSION: HD patients experience ongoing medication-related problems. Reduction in medication-related problems in dialysis patients may improve quality of life and result in decreased morbidity and mortality. Pharmacists are uniquely trained to detect and manage medication-related problems. Pharmacists should be an integral member of the dialysis health care team.

Nondialysis (home) medication utilization and cost in diabetic and nondiabetic hemodialysis patients.

Hemodialysis patients take an average 12 medications (10 at home, 2 in clinic). Cost associated with clinic medications is estimated at 8,429 dollars per patient year at risk, but the medication cost associated with home medications is unknown. Our objective was to determine an estimate of the cost of home medications in the hemodialysis population. Point-prevalent patient medication use data (Jan. 1, 2003) from the Dialysis Clinic Inc. (DCI) national database was used for the study. All patients were classified as patients with diabetes (DM) or patients without diabetes (nonDM), and medication orders were divided into home and in-clinic medications. Home medications were classified as brand (B), generic (G), or brand that could be generic (BG). All home medications were further subcategorized into 12 therapeutic classes. National average medication cost for brand (76.29 dollars) and generic (22.79 dollars) medications were applied to the orders. The medication profiles of 10,230 HD patients were surveyed. Overall, patients were on a mean of 10.1 +/- 4.6 home medications. Currently, 53.4% of the health care dollar is spent on cardiac, gastrointestinal, and phosphate binding medications. DM patients spent significantly more on cardiac, gastrointestinal, and endocrine/hormonal agents (all p < 0.001) whereas nonDM patients spent more on anti-infective agents, analgesics, and phosphate binders (all p < 0.05). Medications for HD patients cost 16,000 dollars per patient per year. Health care providers should be aware of the medication cost burden in HD patients. Efforts to decrease this burden, whether through pharmaceutical care, generic prescribing, or sampling programs, should be considered.