SAN FRANCISCO – Careful monitoring of medication usage by a protocol-driven multidisciplinary team reduced costs in a neuroscience ICU by 30% per patient over a 2-year period while keeping mortality lower than national averages.
“Reviewing and limiting the most expensive drugs in the neuroscience ICU can be done while still achieving quality outcomes,” Dr. Joshua E. Medow said at the annual meeting of the Neurocritical Care Society.
The investigators created a list of the top 15 most-expensive drugs based on per-dose and total-year costs, and made a list of the 15 physicians who used the expensive drugs the most.
Dr. Medow, director of neurocritical care at the University of Wisconsin, Madison, found himself on the list. He made changes in his practice and assessed the results before asking others on the list to use less-expensive alternatives to the costly medications when appropriate.
When possible, they replaced nicardipine at a cost of $1,500/patient per day with nitroprusside and thiosulfate at $50/patient per day, saving $250,000 in a year’s time. They replaced esmolol at $1,200/patient per day with labetalol at $3/patient per day and saved $47,000 in a year. In place of the intravenous formulation of Keppra (levetiracetam), they substituted it with crushed Keppra tablets dissolved in solution and given enterically, which is 200 times cheaper. This shaved $15,000 in costs.
“We also found that patients were receiving albumin at an alarming rate despite little or no evidence of its efficacy in that patient population. Decreasing its use not only decreased cost [by $25,000 yearly] but also reduced patient exposure to processed blood products,” Dr. Medow said.
Cisatracurium at $21 per 10-mg dose wasn’t among the top 15 most expensive drugs, but it gave way to vecuronium at $3.50 per 10-mg dose, for a yearly cost savings of $22,000.
Cumulatively, these and other changes reduced neuroscience ICU drug costs by 30% per patient from 2008 to 2010. Mortality among 1,157 consecutive patients admitted to the neuroscience ICU during that time was below national averages – 44% lower among patients who were ventilated longer than 96 hours, 12% lower among patients ventilated less than 96 hours, and 27% lower among nonintubated patients, Dr. Medow said.
Cost-control efforts may have only just begun, he added. During the time period of the study, antibiotic choices increased costs. Vancomycin use increased expenses by $3,500 and Zosyn (piperacillin and tazobactam combination) use increased costs by $6,500.
“We should be using more Unasyn [ampicillin and sulbactam combination]” and other alternatives for community-acquired infections, he suggested.
Disclosures: Dr. Medow said that he and his coauthors have no pertinent conflicts of interest.