Robert MacLaren1, Tyree H Kiser2, Rose Jung2, Douglas N Fish1. 1. Associate Professor at the University of Colorado School of Pharmacy and Health Sciences Center in Denver, Colorado. 2. Assistant Professor at the University of Colorado School of Pharmacy and Health Sciences Center in Denver, Colorado.
Abstract
OBJECTIVE: In addition to indications for proton pump inhibitors (PPIs) outside the intensive-care unit (ICU), these medications are frequently used to manage nonvariceal upper gastrointestinal (GI) hemorrhage and to prevent stress-related mucosal bleeding in ICU patients. In September 2004, the P&T committee at the University of Colorado Health Sciences Center substituted three PPIs for one less expensive, preferred PPI product; all dosage forms were included. Our goal was to determine whether switching these PPIs to the least expensive agent would alter their usage and associated costs in the ICU (48 beds) and in non-ICU sites (325 beds). METHODS: We conducted analyses of hospital databases before the formulary switch of January 1, 2004, to June 30, 2004, and after the formulary switch of January 1, 2005, to June 30, 2005, to compare the usage and associated drug costs of PPIs and histamine-2 receptor antagonists (H2RAs) in non-ICU and ICU sites. RESULTS: Case-mix indices and length of stay data were similar before and after the switch. The total number of intravenous (IV) and enteral PPI doses charged before and after the switch increased from 1,544 to 4,143 units and from 11,865 units to 17,201 units, respectively. When we adjusted for patient-days, usage patterns of PPIs in non-ICU sites were similar before and after the switch (0.253 and 0.220 units per patient-day, respectively). In contrast, the use of PPIs in the ICU increased after the formulary switch (from 0.942 to 2.056 units per patient-day) as a result of the increased use of both IV PPIs (0.571 to 1.205 units per patient-day) and enteral PPIs (0.371 to 0.852 units per patient-day). Compared with non-ICU usage, the likelihood of PPI use in the ICU was 2.51 times higher after the switch (95% confidence interval [CI], 2.05-3.07; P < .0001).In the ICU, the concomitant use of IV H2RAs decreased from 2.550 to 1.869 units per patient-day. Compared with non-ICU usage, the likelihood of H2RA use in the ICUs was 0.49 times lower (95% CI, 0.39-0.61; P < .0001).Despite increased PPI usage, the cost of acid-suppressant therapy per patient-day in the hospital was similar before and after the switch ($0.65 and $0.59, respectively).In the ICU, the cost of acid-suppressant therapy per patient-day was reduced from $9.66 to $7.80. Compared with non-ICU sites, the cost of acid-suppressant therapy was reduced by 0.72-fold in the ICU after the switch (95% CI, 0.52-1.00, P = .04). CONCLUSION: Substituting a less expensive PPI did not alter usage outside the ICU, but it was associated with increased usage in the ICU. Conversely, the use of IV H2RAs decreased in the ICU. Despite substantially more PPI use after the formulary switch, the cost of acid-suppressant therapy was unchanged overall; it was lower in the ICU, probably as a result of the acquisition drug cost savings associated with the switch.
OBJECTIVE: In addition to indications for proton pump inhibitors (PPIs) outside the intensive-care unit (ICU), these medications are frequently used to manage nonvariceal upper gastrointestinal (GI) hemorrhage and to prevent stress-related mucosal bleeding in ICU patients. In September 2004, the P&T committee at the University of Colorado Health Sciences Center substituted three PPIs for one less expensive, preferred PPI product; all dosage forms were included. Our goal was to determine whether switching these PPIs to the least expensive agent would alter their usage and associated costs in the ICU (48 beds) and in non-ICU sites (325 beds). METHODS: We conducted analyses of hospital databases before the formulary switch of January 1, 2004, to June 30, 2004, and after the formulary switch of January 1, 2005, to June 30, 2005, to compare the usage and associated drug costs of PPIs and histamine-2 receptor antagonists (H2RAs) in non-ICU and ICU sites. RESULTS: Case-mix indices and length of stay data were similar before and after the switch. The total number of intravenous (IV) and enteral PPI doses charged before and after the switch increased from 1,544 to 4,143 units and from 11,865 units to 17,201 units, respectively. When we adjusted for patient-days, usage patterns of PPIs in non-ICU sites were similar before and after the switch (0.253 and 0.220 units per patient-day, respectively). In contrast, the use of PPIs in the ICU increased after the formulary switch (from 0.942 to 2.056 units per patient-day) as a result of the increased use of both IV PPIs (0.571 to 1.205 units per patient-day) and enteral PPIs (0.371 to 0.852 units per patient-day). Compared with non-ICU usage, the likelihood of PPI use in the ICU was 2.51 times higher after the switch (95% confidence interval [CI], 2.05-3.07; P < .0001).In the ICU, the concomitant use of IV H2RAs decreased from 2.550 to 1.869 units per patient-day. Compared with non-ICU usage, the likelihood of H2RA use in the ICUs was 0.49 times lower (95% CI, 0.39-0.61; P < .0001).Despite increased PPI usage, the cost of acid-suppressant therapy per patient-day in the hospital was similar before and after the switch ($0.65 and $0.59, respectively).In the ICU, the cost of acid-suppressant therapy per patient-day was reduced from $9.66 to $7.80. Compared with non-ICU sites, the cost of acid-suppressant therapy was reduced by 0.72-fold in the ICU after the switch (95% CI, 0.52-1.00, P = .04). CONCLUSION: Substituting a less expensive PPI did not alter usage outside the ICU, but it was associated with increased usage in the ICU. Conversely, the use of IV H2RAs decreased in the ICU. Despite substantially more PPI use after the formulary switch, the cost of acid-suppressant therapy was unchanged overall; it was lower in the ICU, probably as a result of the acquisition drug cost savings associated with the switch.
Authors: Steven A Conrad; Andrea Gabrielli; Benjamin Margolis; Andrew Quartin; J Steven Hata; William O Frank; Robert G Bagin; James A Rock; Bonnie Hepburn; Loren Laine Journal: Crit Care Med Date: 2005-04 Impact factor: 7.598
Authors: Alan Barkun; Carlo A Fallone; Naoki Chiba; Marty Fishman; Nigel Flook; Janet Martin; Alaa Rostom; Anthony Taylor Journal: Can J Gastroenterol Date: 2004-10 Impact factor: 3.522