PHARMACOECONOMICS Edited by William F. MeGhan, J. Lyle Bootman, and Raymond J. Townsend
INTRAVENOUS-TO-ORAL STEPDOWN PROGRAM: FOURYEARS OF EXPERIENCE IN A LARGE TEAClllNG HOSPITAL Luciana Frighetto, Donna Nickoloff, Shelagh M. Martinusen, Fatima S. Mamdani, and Peter J. J ewesson
OBJECTIVE: To assess the impact of an intravenous-to-oral (iv-po) stepdown program on the relative use of oral and parenteral dosage forms of select antimicrobials.
A retrospective review of drug utilization records before and after a trial comparing metronidazole and c1indamycin prescribing trends from a 12-month baseline period to a four-year follow-up period. DESIGN:
SETIING:
One thousand-bed Canadian tertiary care referral teaching
center. INTERVENTION: An authorized iv-po stepdown program was developed to promote the oral route of drug administration. Reminders of iv-po stepdown were produced for metronidazole and c1indamycin and these notes were sent to nursing units with the parenteral dosage form. The notes then were attached to the front of the health record to serve as a reminder to prescribers that an equally
LUCIANA FRIGHETTO, B.Sc.(Phann.). DONNA NICKOLOFF, B.Sc.(Phann.). SHELAGH M. MARTINUSEN, B.Sc.(Phann.). and FATIMA S. MAMDANI, B.Sc.(Phann.J, are Drug Use Evaluation Pharmacists, Vancouver General Hospital; and PETER J. JEWESSON, Ph.D .. is the Director, Department of Pharmacy, Vancouver General Hospital, an Associate Professor, Faculty of Pharmaceutical Sciences, University of British Columbia. and a Clinical Instructor, Division of Infectious Diseases, Department of Medicine, Vancouver General Hospital. Reprints: Peter J. Jewesson, Ph.D., Director, Pharmacy Services, Vancouver General Hospital, 855 W. 12th Ave., Vancouver. BC. Canada V5Z IM9. WILLIAM F, MCGHAN, Phann.D., Ph.D., is a Professor and the Executive Director, Institute for Pharmaceutical Economics. and the Chairman, Department of Pharmacy Practice and Phannacy Administration, Philadelphia College of Pharmacy and Science, Philadelphia, PA; J. LYLE BOOTMAN, Ph.D., is a Professor and the Dean, College of Pharmacy, University of Arizona. Tucson, AZ 85721; RAYMOND J. TOWNSEND, Phann.D.. is the Vice President, Applied Healthcare Research, Glaxo Inc., Research Triangle Park, NC 27709.
effective, well-tolerated, and less-expensive oral dosage form was available for use. A 44 percent relative increase in the use of oral metronidazole and a 79 percent relative increase in the use of oral c1indamycin occurred. When acquisition and delivery costs were considered, cumulative cost savings from 1988 to 1991 resulted for metronidazole ($31 920) and c1indamycin ($53 880). RESULTS:
This intervention represents a simple yet effective method of promoting a process of stepdown from parenteral to oral antibiotic therapy. CONCLUSIONS:
AnnPharmacother 1992;26:1447-51.
DRUG COSTS CONTINUE TO ESCALATE in the acute care hospital setting. From 1991 to 1992, total drug expenditures at Vancouver General Hospital, a WOO-bed Canadian tertiary care referral teaching center, were $10.2 million. Thirtyone percent ($3.2 million) of this cost was associated with antiinfective agents; antibacterial drugs accounted for 70 percent of the total antiinfective expenditures. We have described a simple method that we implemented to promote the use of oral dosage forms of select antimicrobials as a method of containing drug costs in this hospital" This intravenous-to-oral (iv-po) stepdown program has now been in place for four years and this report is intended as an update of our experience. In March 1987, we implemented the iv-po stepdown program through the drug use evaluation program, department of pharmacy, with the endorsement of the antimicrobial
The Annals ofPharmacotherapy • Downloaded from aop.sagepub.com at CORNELL UNIV on October 12, 2016
1992 November, Volume 26 •
1447
utilization subcommittee of the pharmacy and therapeutics committee and the medical advisory committee in this hospital. IV-PO stepdown reminders (IPSRs) were developed to promote the oral route of drug administration for select
VANCOUVER GENERAL HOSPITAL
PHARMACY DEPARTMENT
~ORAL =LV. clindamycin oral • • •
agents (Figure I). In March 1988, IPSRs were developed for metronidazole and clindamycin. These notes are sent to the nursing unit with the parenteral dosage form on day 3 of therapy (date of first refill) and are attached to the front of the patient's chart by the nursing staff, The notes are a highly visible bright yellow and contain a brief, specific message regarding the cost advantage of using the oral dosage form . IPSRs serve as a reminder to prescribers that an oral dosage form is available for use when the patient 's condition permits, Four-year utilization trends for metronidazole and clindamycin are shown in Figure 2. The oral dosage form of metronidazole represented 36 percent of total oral and parenteral SOO-mg dosage units dispensed during a 12-month
clindamycin is: well absorbed well tolerated less expensive
VANCOUVER GENERAl HOSPITAL PHARMACY DEPARTMENT
PLEASE SWITCH FROM I.V. ($40/DAY)
TO ORAL (S4 Iday) AS SOON AS POSSIBLE
(Pallent
SoN ame
)
ATTACH TO FRONT OF PATIENT'S CHART 3- 88
Figure I. lntravenous-to-oral stepdown reminder (front).
Oral Doses (% Total) 70 .---=--,---,--~,.-----,---------,.----,.------, IP_'.N-J
ATTACH TO FRONT OF PATIENT'S CHART Figure 3A. Modified intraven ous-t o-oral ste pdown reminder for clindamycin (front) .
50
CLINDAMYCIN DISPOSITION
40
ORAL VS PARENTERAL DOSAGE FORMS SERUM CONC. (mg/ll 6,------------,
DOSE AND ROUTE 3
-300MGPO +3OOMGlV
' 2
1
MICceO)
.'.ph
II
0 0
'88/89
'89/90
'90/91
1
'91/92
0 . ' ""elL"
2
3
4
,
5~-'6- ':' 8 9 101112 TIME (h)
Type.I ""'"' '-wi, .n... _ngl. doN ~pted from: DeHun R ..... J CHn F'hannacoI1D73;13:t90-2OSI, ....y Rft .. aI. Alnt HZ J M_ '074 " ~.34 ·. ' 5.
Fiscal Year Figure 2. Utilization trends for metronid azole and clindamycin.• = clindamycin; • metronidazole.
=
1448 •
.ur.u.
'1'_8 Uf'P Q .a_""Cl/L
The Annals ofPharmacotherapy
•
Figure 3B. Modified intravenous-to-oral stepdown reminder for clindamycin (back ).
1992 November. Volume 26
Downloaded from aop.sagepub.com at CORNELL UNIV on October 12, 2016
IV·PO Stepdown Program
period prior to implementation of the program. Over the subsequent four years, this increased to an average of 52 percent of the total, representing a 44 percent relative increase in the use of the oral dosage form (chi-square =4.57, p=O.03). The oral dosage form of clindamycin represented 14 percent of total oral and parenteral600-mg dosage units dispensed during a 12-month period prior to implementation of the program. Over the subsequent four years, this increased to an average of 25 percent of the total, representing a 79 percent relative increase in the use of the oral dosage form (chi-square =3.19, p=O.07). We have estimated the cost of acquisition, preparation, and delivery of parenteral and oral dosage forms in this
VANCOUVER
GENERAl.
hospital (Table I). When acquisition and delivery (preparation and administration) costs are considered, we estimate the cumulative cost savings from 1988 to 1991 to be $31920 for metronidazole and $53 880 for clindamycin. This intervention has continued to be a simple yet effective method of promoting a process of stepdown from parenteral to oral antibiotic therapy. The program is inexpenVANCOUVER GENERAL HOSPITAL PHARMACY DEPARTMENT
IV - PO STEPDOWN PROGR
'~~6) CIPROF ' , XACIN
HOSPITAL /
PHARMACY DEPARTMENT
.
.....-:.,
J
,, ""'
.. :.::, ~
.
ciPr~ifixaCin J\\
.- : , • \ well tolefated / \. • H(SS expensive ! \ • in~icated: for stepdo wn\ therepv (see reverse) \ 200MG IV Q12H\ \
\
.
tOOMG PO Q12.:r-\
$3~.OOIDAY )
~ $7.30IDA
~~WITCH FRO »>: . ~'v.:'~':=~:':::-~::'.~ ..
.,
.
"'~§~ITCH FROM;:nL~~~~;/ AS SOO~ POSSIBLE
,
/
'~'\:; ..r-: :.. ': •
~.
'-
J
'IV-!2.J:-
AS SOON AS POSSIBLE
ATIACH TO FRONT OF PATIENT'S CHART Figure 4A. New intravenous-to-oral stepdown reminder for ciprolloxacin (front).
/~. Stepdown Criteria
l P _·.N_1
ATTACH TO FRONT OF PATIENT'S CHART Figure 3C. Modified intravenous-to-oral stepdown reminder for metronidazole (front).
METRONIDAZOLE DISPOSITION ORAL VS PARENTERAL DOSAGE FORMS SERUM CONC. (mg/L) 30-------·
;0"'"0
,ouj
• 500MG PO
-+-500MG IV --------
10
5
- - - - - - . - - - - - - - - - - - ---.- - - - - -
o o
'~ - -
- - ----- ----- - ,. -_.-
Oral therapy should be considered if the patient: • • •
continues to require the drug is clinically stable is capable of tolerating the oral dosage Ciprofloxacin interacts with antacids! sucralfate; space doses :L2hrs apart
Stepdown regimens: 1200MG IV Q 12H -+ 500MG PO Q 12H 1400MG IV Q 12H -+ 750MG PO Q 12H
MIC (90)
} G,am +VE An ... ob •• 2,"mglL B. I'.gms group
INTRAVENOUS-TO-ORAL STEPDOWN PROGRAM: FOURYEARS OF EXPERIENCE IN A LARGE TEAClllNG HOSPITAL Luciana Frighetto, Donna Nickoloff, Shelagh M. Martinusen, Fatima S. Mamdani, and Peter J. J ewesson
OBJECTIVE: To assess the impact of an intravenous-to-oral (iv-po) stepdown program on the relative use of oral and parenteral dosage forms of select antimicrobials.
A retrospective review of drug utilization records before and after a trial comparing metronidazole and c1indamycin prescribing trends from a 12-month baseline period to a four-year follow-up period. DESIGN:
SETIING:
One thousand-bed Canadian tertiary care referral teaching
center. INTERVENTION: An authorized iv-po stepdown program was developed to promote the oral route of drug administration. Reminders of iv-po stepdown were produced for metronidazole and c1indamycin and these notes were sent to nursing units with the parenteral dosage form. The notes then were attached to the front of the health record to serve as a reminder to prescribers that an equally
LUCIANA FRIGHETTO, B.Sc.(Phann.). DONNA NICKOLOFF, B.Sc.(Phann.). SHELAGH M. MARTINUSEN, B.Sc.(Phann.). and FATIMA S. MAMDANI, B.Sc.(Phann.J, are Drug Use Evaluation Pharmacists, Vancouver General Hospital; and PETER J. JEWESSON, Ph.D .. is the Director, Department of Pharmacy, Vancouver General Hospital, an Associate Professor, Faculty of Pharmaceutical Sciences, University of British Columbia. and a Clinical Instructor, Division of Infectious Diseases, Department of Medicine, Vancouver General Hospital. Reprints: Peter J. Jewesson, Ph.D., Director, Pharmacy Services, Vancouver General Hospital, 855 W. 12th Ave., Vancouver. BC. Canada V5Z IM9. WILLIAM F, MCGHAN, Phann.D., Ph.D., is a Professor and the Executive Director, Institute for Pharmaceutical Economics. and the Chairman, Department of Pharmacy Practice and Phannacy Administration, Philadelphia College of Pharmacy and Science, Philadelphia, PA; J. LYLE BOOTMAN, Ph.D., is a Professor and the Dean, College of Pharmacy, University of Arizona. Tucson, AZ 85721; RAYMOND J. TOWNSEND, Phann.D.. is the Vice President, Applied Healthcare Research, Glaxo Inc., Research Triangle Park, NC 27709.
effective, well-tolerated, and less-expensive oral dosage form was available for use. A 44 percent relative increase in the use of oral metronidazole and a 79 percent relative increase in the use of oral c1indamycin occurred. When acquisition and delivery costs were considered, cumulative cost savings from 1988 to 1991 resulted for metronidazole ($31 920) and c1indamycin ($53 880). RESULTS:
This intervention represents a simple yet effective method of promoting a process of stepdown from parenteral to oral antibiotic therapy. CONCLUSIONS:
AnnPharmacother 1992;26:1447-51.
DRUG COSTS CONTINUE TO ESCALATE in the acute care hospital setting. From 1991 to 1992, total drug expenditures at Vancouver General Hospital, a WOO-bed Canadian tertiary care referral teaching center, were $10.2 million. Thirtyone percent ($3.2 million) of this cost was associated with antiinfective agents; antibacterial drugs accounted for 70 percent of the total antiinfective expenditures. We have described a simple method that we implemented to promote the use of oral dosage forms of select antimicrobials as a method of containing drug costs in this hospital" This intravenous-to-oral (iv-po) stepdown program has now been in place for four years and this report is intended as an update of our experience. In March 1987, we implemented the iv-po stepdown program through the drug use evaluation program, department of pharmacy, with the endorsement of the antimicrobial
The Annals ofPharmacotherapy • Downloaded from aop.sagepub.com at CORNELL UNIV on October 12, 2016
1992 November, Volume 26 •
1447
utilization subcommittee of the pharmacy and therapeutics committee and the medical advisory committee in this hospital. IV-PO stepdown reminders (IPSRs) were developed to promote the oral route of drug administration for select
VANCOUVER GENERAL HOSPITAL
PHARMACY DEPARTMENT
~ORAL =LV. clindamycin oral • • •
agents (Figure I). In March 1988, IPSRs were developed for metronidazole and clindamycin. These notes are sent to the nursing unit with the parenteral dosage form on day 3 of therapy (date of first refill) and are attached to the front of the patient's chart by the nursing staff, The notes are a highly visible bright yellow and contain a brief, specific message regarding the cost advantage of using the oral dosage form . IPSRs serve as a reminder to prescribers that an oral dosage form is available for use when the patient 's condition permits, Four-year utilization trends for metronidazole and clindamycin are shown in Figure 2. The oral dosage form of metronidazole represented 36 percent of total oral and parenteral SOO-mg dosage units dispensed during a 12-month
clindamycin is: well absorbed well tolerated less expensive
VANCOUVER GENERAl HOSPITAL PHARMACY DEPARTMENT
PLEASE SWITCH FROM I.V. ($40/DAY)
TO ORAL (S4 Iday) AS SOON AS POSSIBLE
(Pallent
SoN ame
)
ATTACH TO FRONT OF PATIENT'S CHART 3- 88
Figure I. lntravenous-to-oral stepdown reminder (front).
Oral Doses (% Total) 70 .---=--,---,--~,.-----,---------,.----,.------, IP_'.N-J
ATTACH TO FRONT OF PATIENT'S CHART Figure 3A. Modified intraven ous-t o-oral ste pdown reminder for clindamycin (front) .
50
CLINDAMYCIN DISPOSITION
40
ORAL VS PARENTERAL DOSAGE FORMS SERUM CONC. (mg/ll 6,------------,
DOSE AND ROUTE 3
-300MGPO +3OOMGlV
' 2
1
MICceO)
.'.ph
II
0 0
'88/89
'89/90
'90/91
1
'91/92
0 . ' ""elL"
2
3
4
,
5~-'6- ':' 8 9 101112 TIME (h)
Type.I ""'"' '-wi, .n... _ngl. doN ~pted from: DeHun R ..... J CHn F'hannacoI1D73;13:t90-2OSI, ....y Rft .. aI. Alnt HZ J M_ '074 " ~.34 ·. ' 5.
Fiscal Year Figure 2. Utilization trends for metronid azole and clindamycin.• = clindamycin; • metronidazole.
=
1448 •
.ur.u.
'1'_8 Uf'P Q .a_""Cl/L
The Annals ofPharmacotherapy
•
Figure 3B. Modified intravenous-to-oral stepdown reminder for clindamycin (back ).
1992 November. Volume 26
Downloaded from aop.sagepub.com at CORNELL UNIV on October 12, 2016
IV·PO Stepdown Program
period prior to implementation of the program. Over the subsequent four years, this increased to an average of 52 percent of the total, representing a 44 percent relative increase in the use of the oral dosage form (chi-square =4.57, p=O.03). The oral dosage form of clindamycin represented 14 percent of total oral and parenteral600-mg dosage units dispensed during a 12-month period prior to implementation of the program. Over the subsequent four years, this increased to an average of 25 percent of the total, representing a 79 percent relative increase in the use of the oral dosage form (chi-square =3.19, p=O.07). We have estimated the cost of acquisition, preparation, and delivery of parenteral and oral dosage forms in this
VANCOUVER
GENERAl.
hospital (Table I). When acquisition and delivery (preparation and administration) costs are considered, we estimate the cumulative cost savings from 1988 to 1991 to be $31920 for metronidazole and $53 880 for clindamycin. This intervention has continued to be a simple yet effective method of promoting a process of stepdown from parenteral to oral antibiotic therapy. The program is inexpenVANCOUVER GENERAL HOSPITAL PHARMACY DEPARTMENT
IV - PO STEPDOWN PROGR
'~~6) CIPROF ' , XACIN
HOSPITAL /
PHARMACY DEPARTMENT
.
.....-:.,
J
,, ""'
.. :.::, ~
.
ciPr~ifixaCin J\\
.- : , • \ well tolefated / \. • H(SS expensive ! \ • in~icated: for stepdo wn\ therepv (see reverse) \ 200MG IV Q12H\ \
\
.
tOOMG PO Q12.:r-\
$3~.OOIDAY )
~ $7.30IDA
~~WITCH FRO »>: . ~'v.:'~':=~:':::-~::'.~ ..
.,
.
"'~§~ITCH FROM;:nL~~~~;/ AS SOO~ POSSIBLE
,
/
'~'\:; ..r-: :.. ': •
~.
'-
J
'IV-!2.J:-
AS SOON AS POSSIBLE
ATIACH TO FRONT OF PATIENT'S CHART Figure 4A. New intravenous-to-oral stepdown reminder for ciprolloxacin (front).
/~. Stepdown Criteria
l P _·.N_1
ATTACH TO FRONT OF PATIENT'S CHART Figure 3C. Modified intravenous-to-oral stepdown reminder for metronidazole (front).
METRONIDAZOLE DISPOSITION ORAL VS PARENTERAL DOSAGE FORMS SERUM CONC. (mg/L) 30-------·
;0"'"0
,ouj
• 500MG PO
-+-500MG IV --------
10
5
- - - - - - . - - - - - - - - - - - ---.- - - - - -
o o
'~ - -
- - ----- ----- - ,. -_.-
Oral therapy should be considered if the patient: • • •
continues to require the drug is clinically stable is capable of tolerating the oral dosage Ciprofloxacin interacts with antacids! sucralfate; space doses :L2hrs apart
Stepdown regimens: 1200MG IV Q 12H -+ 500MG PO Q 12H 1400MG IV Q 12H -+ 750MG PO Q 12H
MIC (90)
} G,am +VE An ... ob •• 2,"mglL B. I'.gms group
