The appropriateness of human albumin use in the hospital of Padova, Italy

How albumin administration for cirrhosis impacts on hospital albumin consumption and expenditure

AIM: To assess the impact of guidelines for albumin prescription in an academic hospital, which is a referral center for liver diseases.

METHODS: Although randomized trials and guidelines support albumin administration for some complications of cirrhosis, the high cost of albumin greatly limits its use in clinical practice. In 2003, a multidisciplinary panel at Sant’Orsola-Malpighi University Hospital (Bologna, Italy) used a literature-based consensus method to list all the acute and chronic conditions for which albumin is indicated as first- or second-line treatment. Indications in hepatology included prevention of post-paracentesis circulatory dysfunction and renal failure induced by spontaneous bacterial peritonitis, and treatment of hepatorenal syndrome and refractory ascites. Although still debated, albumin administration in refractory ascites is accepted by the Italian health care system. We analyzed albumin prescription and related costs before and after implementation of the new guidelines.

RESULTS: While albumin consumption and costs doubled from 1998 to 2002, they dropped 20% after 2003, and remained stable for the following 6 years. Complications of cirrhosis, namely refractory ascites and paracentesis, represented the predominant indications, followed by major surgery, shock, enteric diseases, and plasmapheresis. Albumin consumption increased significantly after guideline implementation in the liver units, whereas it declined elsewhere in the hospital. Lastly, extra-protocol albumin prescription was estimated as < 10%.

CONCLUSION: Albumin administration in cirrhosis according to international guidelines does not increase total hospital albumin consumption if its use in settings without evidence of efficacy is avoided.

Costs related to inappropriate use of albumin in Spain

BACKGROUND

Albumin has been used in various treatments for > 50 years, but, recently, its use in clinical practice has become very controversial.

OBJECTIVE

To assess the use of albumin in clinical practice in the public hospital setting in Andalucía, Spain, focusing on the economic repercussions of the inappropriate use of albumin.

METHODS

Multicentered observational study in 22 public hospitals in which all patients receiving albumin (from start to conclusion of treatment) were assessed during a five-month period on three predetermined, nonconsecutive days. The clinical indications for albumin were evaluated on the basis of Guidelines, a consensus document created by a multidisciplinary team for dissemination by the Governmental Health Authority to all hospitals within its purview. The data were abstracted from the patient case report forms by the pharmacist selected to compile the data in each of the participating hospitals.

RESULTS

A total of 242 forms reporting the use of 62,282 g of albumin were evaluated. The most frequent prescribing motives were nutritional intervention (23%), paracentesis in cirrhotic patients (19%), and radical surgery (11%). Only 59 prescriptions (24%), corresponding to 14,539 g of albumin (23%), were considered appropriate. The total cost of albumin therapy for the 242 cases was $183,796 (US$); $42,905 (23%) of this figure was the cost of appropriate use of albumin and $140,891 (77%) was the amount related to inappropriate use.

CONCLUSIONS

Evaluated against model guidelines, the use of most of the albumin, deemed clinically necessary by the prescribers, was considered unnecessary or inappropriate. Hence, institutions need to define and implement guidelines that focus on responsible use of such agents in an increasingly cost-conscious healthcare environment.

[Economic impact of a prescription protocol in an intensive care unit]

OBJECTIVE

To assess the economic impact of a prescribing protocol for i.v. fluid therapy and artificial nutrition.

STUDY DESIGN

Comparative study, before and during use of the protocol.

PATIENTS

The study included 555 ICU patients allocated into two groups, before and after starting with the protocol. The groups were comparable for number, pathologies, age, severity score, duration of ICU stay, incidence of nosocomial infections, mortality rate.

METHOD

In February 1995, a written literature-based prescribing protocol for fluid therapy (hydroxyethylstarch and albumin), and artificial nutrition (enteral nutrition as first-line therapy) was devised. A cost analysis was made for two 6-month periods: before (August 1994 to January 1995) and after start of protocol (February to July 1995).

RESULTS

The prescription of albumin and hydroxyethylstarch decreased (by 33 and 58% respectively), whereas administration of Ringer lactate and gelatine solutes increased simultaneously. This induced a cost saving of 15,000 FF (a 20% decrease in cost). The reduction of parenteral nutrition in favour of early enteral nutrition induced a cost saving of 56,000 FF (31% decrease in cost).

CONCLUSION

Our prescribing protocol generated a cost saving of 9% of the pharmaceutical budget and decreased the cost-benefit ratio of our ICU.

Use of albumin in intensive care unit patients--is continuous quality assessment necessary?

BACKGROUND

There are two main reasons for hypo-albuminaemia in severely ill patients: long-lasting malnutrition and metabolic response to stress. Hypo-albuminaemia is therefore a prognostic indicator of illness severity rather than a cause of disease. Supplementation with albumin has not yet been demonstrated to have measurable therapeutic effects. Hypovolaemia is often seen in intensive care unit (ICU) patients, either postoperatively or caused through shock. The main goal of any treatment is to maintain adequate intravascular filling. No clear benefit can be seen when using albumin instead of artificial colloids.

OBJECTIVE

Based on the literature, we performed an intervention study to evaluate and improve the use of albumin.

METHOD

After evaluation of the use of albumin over the last 4 years (by means of analysis of the pharmacy drug use statistics), all staff members of the ICU were invited to discuss information retrieved from recently published literature. This led to the introduction of the following new guidelines. Albumin may only be given to patients with very low serum albumin levels of less than 15 g/litre. Substitution of albumin between levels of 15-20 g/litre may take place if patients are in poor condition. The indication has to be documented in the patient's notes.

RESULTS

After the introduction of the guidelines, the use of albumin dropped by more than 50% from 3178 units in 1996 to 1565 units in 1997. This led to direct cost savings of approximately US$100000.

CONCLUSION

The available literature about the risks and benefits of using albumin in clinical practice is not conclusive. The use of albumin should therefore be restricted according to the guidelines.