August 21, 2014

Pharmacy’s targeted initiatives lead to lower drug expenses

Vanderbilt University Hospital’s pharmacy is attracting national attention for reducing its inpatient pharmacy drug expenses 6.4 percent in a 12-month period, despite an increase in patient volume.

VUMC’s pharmacies have managed to reduce inpatient drug expenses by 6.4 percent over the previous year. (photo by Susan Urmy)

Vanderbilt University Hospital’s pharmacy is attracting national attention for reducing its inpatient pharmacy drug expenses 6.4 percent in a 12-month period, despite an increase in patient volume.

The University HealthSystem Consortium (UHC) in August named Vanderbilt “Most Improved” in its database of hospitals in the category of inpatient drug expense. While drug expenses dropped more than 6 percent, costs shot up 6.5 percent for the median of facilities UHC tracked over the same period, from April 2013 to March 2014.

Vanderbilt’s inpatient pharmacy drug spending reduction, nearly $5 million from fiscal years 2013 to 2014, was accomplished in an “evidence-based medicine” culture seeking to improve patient care by ensuring that medications are only used when truly necessary, at the lowest effective dose and for the shortest effective duration.

Bob Lobo, Pharm.D.

“We believe that with continued efforts by the pharmacists that practice in these areas and the continued support of our physician leaders, we’ll be able to maintain the reduced utilization of these target drugs and continue these cost savings year over year,” said Bob Lobo, Pharm.D., director of Clinical Programs for the Department of Pharmaceutical Services.

As part of an organization-wide effort to find cost-savings, Lobo said Vanderbilt’s pharmacy set a goal in fiscal year 2013 to cut inpatient drug utilization costs by at least $2 million by the end of the 2014 fiscal year without reducing quality of care or patient safety.

“The pharmacy worked closely with the Pharmacy and Therapeutics Committee (P&T Committee) to enact programs, policies, protocols and educational initiatives that would improve cost-effectiveness and reduce expenses while maintaining or improving clinical quality,” he said.

The committee, which is made up of about 16 physicians, reports to the Vanderbilt University Medical Center Medical Board. It reviewed and approved more than 20 target drug initiatives, 17 of which were implemented during fiscal year 2014.

“Over many years, the P&T Committee has consistently worked to insert evidence-based guidance into the care delivery system, usually through prompts embedded in our Horizon Expert Orders System, so as to optimize the quality, safety and cost-effectiveness of patient care,” said Gordon Bernard, M.D., Melinda Owen Bass Professor of Medicine, associate vice chancellor for Clinical and Translational Research and chair of the P&T Committee.

In addition to the target drug initiatives, Pharmacy staffers looked for savings throughout the supply chain, in contracts and by optimizing its inventory.

“We made changes to how these medications are ordered in our computerized provider order entry system,” Lobo said, “so that advice was available to the ordering provider at the point of care, at the point of ordering the medication, in order to ensure the most optimal, safest, most effective way of using the medication.”

Pharmacy staffers partnered with colleagues in the Department of Pharmacy Informatics to develop sophisticated clinical decision support tools for the medication ordering system. In addition, a software program was used to track drug utilization at the patient, location and physician level in near real time.

Data on drug utilization and costs were used to create reports, educate physicians and ensure compliance to policies and protocols to help ensure the most effective course of treatment at the lowest possible cost. The P&T Committee reviewed the reports each month.

The program’s result: reduced drug costs with simultaneously improved patient care. One example is a reduction in the use of Precedex, a sedative used in surgery and intensive care areas. Lobo said Vanderbilt’s sedation guidelines call for it to be used as a third-line drug, after two well-accepted alternatives have been tried and individual patient results have not been optimal.

However, prior to implementing these changes, Precedex was sometimes being used as a first-line drug. The data on Precedex use was shared with clinical pharmacists and ICU medical directors who sought to establish Vanderbilt’s sedation protocol, which restricts Precedex use.
“As a side benefit of improving our compliance with the protocol, we reduced our spending on Precedex,” Lobo said, by nearly $400,000 over the year period.

Another example is the restriction of carbapenems, a class of antibiotics used to treat severe, life-threatening infections. They are considered a drug of last resort for many patients, and should be used conservatively because of the growing problem of resistance, Lobo said.

Restricting carbapenems fits with Vanderbilt’s larger initiative to control the use of very broad-spectrum antimicrobial drugs when narrower spectrum options would be just as effective so as to reduce the development of resistance to such drugs. Antimicrobial stewardship efforts targeted at this class of drugs saved $133,000 over the year period.

There were many other initiatives that were successful, with savings ranging from $13,000 to $700,000.

“This is really part of a cultural change for us to be more efficient and less wasteful with our resources,” Lobo said.