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Forster CM, Halls S, Allarakhia S, Modi D, Chung W, Derry K, Digby G, Flemming J, McGugan J, Mackulin H, Montague S, Sibley S, Silver SA, Sirosky-Yanyk A, Stevens A, de Wit K, Zhang L, Callum J. Improving appropriate use of intravenous albumin: results of a single-centre audit and multifaceted intervention. BMJ Open Qual 2024; 13:e002534. [PMID: 38626937 PMCID: PMC11029189 DOI: 10.1136/bmjoq-2023-002534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Intravenous albumin has limited indications supported by randomised controlled trials, yet it is often prescribed for indications not supported by evidence. AIM To reduce unnecessary transfusion of albumin. INTERVENTIONS Under the leadership of a multidisciplinary quality improvement team, evidence-based recommendations were disseminated in tandem with a new electronic order set, an educational strategy, qualitative interviews with prescribers and a return policy change to reduce wastage. IMPLEMENTATION AND EVALUATION Interventions were introduced in a staggered fashion. The primary outcome, appropriate use of albumin, was monitored and quantified using pre-intervention and post-intervention audits. Process measures included statistical process run charts of monthly usage of 5% and 25% albumin and wastage. Data on length of stay (hospital and intensive care), new inpatient starts on kidney replacement and mortality were collected as balancing measures. RESULTS Appropriate albumin usage based on indication increased from 30% to 50% (p<0.0001). There was significantly less overall albumin usage in the post-intervention period compared with the pre-intervention period (negative coefficient, p<0.0001), driven by a major reduction in the utilisation of the 5% formulation (p<0.0001). Overall albumin usage was significantly lower in the post-intervention period, decreasing from 800 to 450 vials per month. The intervention resulted in significantly less wastage (negative coefficient, p=0.017). Mortality, length of stay and new starts on kidney replacement therapy remained constant throughout the study period. CONCLUSION Improved prescribing of albumin was achieved with a multifaceted approach. Substantial and sustained reductions in usage were achieved without negatively impacting patient-important outcomes. The estimated annual savings for the purchase cost of albumin was CAN $300 000. We provide a structured process for other organisations to optimise their use of albumin.
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Affiliation(s)
- Corey M Forster
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | | | - Dimpy Modi
- Department of Medicine, Hamilton, Stockholm, Ontario, Sweden
| | - Wiley Chung
- Surgery, Queen's University, Kingston, Ontario, Canada
| | - Kendra Derry
- Department of Anesthesiology, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jennifer Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John McGugan
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Heather Mackulin
- Nursing, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Steven Montague
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Samuel A Silver
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Angela Sirosky-Yanyk
- Transfusion Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Andrew Stevens
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Liying Zhang
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jeannie Callum
- Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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Altawalbeh SM, Almestarihi EM, Khasawneh RA, Momany SM, Abu Hammour K, Shawaqfeh MS, Abraham I. Cost-effectiveness of intravenous resuscitation fluids in sepsis patients: a patient-level data analysis in Jordan. J Med Econ 2024; 27:126-133. [PMID: 38105744 DOI: 10.1080/13696998.2023.2296196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 12/19/2023]
Abstract
AIM Albumin role as fluid resuscitation in sepsis remains understudied in low- and middle-income countries. This study aimed to evaluate the cost-effectiveness of intravenous (IV) Albumin compared to Crystalloids in sepsis patients using patient-level data in Jordan. METHODS This was a retrospective cohort study of sepsis patients aged 18 or older admitted to intensive care units (ICU) at two major tertiary hospitals during the period 2018-2019. Patients information, type of IV fluid, and clinical outcomes were retrieved from medical records, and charges were retrieved from the billing system. A 90-day partitioned survival model with two health states (alive and dead) was constructed to estimate the survival of sepsis patients receiving either Albumin or Crystalloids as IV fluids for resuscitation. Overall survival was predicted by fitting a Weibull model on the patient-level data from the current study. To further validate the results, and to support the assessment of uncertainty, time-dependent transition probabilities of death at each cycle were estimated and used to construct a state-transition patient-level simulation model with 10,000 microsimulation trials. Adopting the healthcare system perspective, incremental cost-effectiveness ratios(ICERs) of Albumin versus Crystalloids were calculated in terms of the probability to be discharged alive from the ICU. Uncertainty was explored using probabilistic sensitivity analysis. RESULTS In the partitioned survival model, Albumin was associated with an incremental cost of $1,007 per incremental1% in the probability of being discharged alive from the ICU. In the state-transition patient-level simulation model, ICER was $1,268 per incremental 1% in the probability of being discharged alive. Probabilistic sensitivity analysis showed that Albumin was favored at thresholds >$800 per incremental 1%in the probability of being discharged alive from the ICU. CONCLUSION IV Albumin use in sepsis patients might not be cost-effective from the healthcare perspective of Jordan. This has important implications for policymakers to readdress Albumin prescribing practice in sepsis patients.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Eman M Almestarihi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Rawand A Khasawneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Suleiman M Momany
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khawla Abu Hammour
- Department of Biopharmaceutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan
| | - Mohammad S Shawaqfeh
- Department of pharmacy practice, College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
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