Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT

Abstract

Purpose:To estimate the effect of an oral 13-hour inpatient corticosteroid premedication regimen on length of stay, hospital cost, and hospital-acquired infections (HAIs) by using a combination of real and hypothetical study populations. Materials and Methods:Institutional review board approval was obtained and informed consent waived for this HIPAA-compliant retrospective study. Inpatients who received an oral 13-hour corticosteroid premedication regimen before contrast material-enhanced CT (n = 1424) from 2008 to 2013 were matched by age, sex, and year when CT was performed to a control cohort (n = 1425) of patients who underwent contrast-enhanced CT without premedication and who had similar rates of 13 comorbid diseases. Length of stay in the hospital and time from admission to CT were compared by using the Mann-Whitney U test. Rates of prospectively reported HAIs were compared by using x 2 tests. The indirect cost and risk of HAI with premedication were estimated by using published data. Results:Premedicated inpatients had a significantly longer median length of stay (+25 hours; 158 vs 133 hours, P , .001), a significantly longer median time to CT (+25 hours, 42 vs 17 hours, respectively; P , .001), and a significantly greater risk of HAI (5.1% [72 of 1424] vs 3.1% [44 of 1424], respectively; P = .008) compared with nonpremedicated control subjects. On the basis of these data and existing references, the prolonged length of stay was estimated to result in 0.04 HAI-related deaths and a cost of $159 131 (in U.S. dollars) for each prevented reaction of any severity and 32 HAI-related deaths and a cost of $131 211 400 for each prevented reaction-related death. Conclusion:Oral 13-hour inpatient corticosteroid prophylaxis is associated with substantial cost relative to its modest benefit, and may cause more indirect harm than the direct harm that it prevents.q RSNA, 2015

Intravenous Corticosteroid Premedication Administered 5 Hours before CT Compared with a Traditional 13-Hour Oral Regimen

“…It consists of 50 mg of oral prednisone administered at 13 hours, 7 hours, and 1 hour before computed tomography (CT) and 50 mg of oral diphenhydramine 1 hour before CT (3)(4)(5)(6). However, in some patients who are at risk for a reaction to contrast media, waiting 13 hours is not desirable (4,7), either because medical urgency makes a timelier radiologic examination necessary or the care is being performed in a high-risk environment with collateral risk (eg, inpatient hospitalization) (8).…”

“…Minimizing the duration of prophylaxis is advantageous to accelerate diagnosis in emergent situations but also to reduce the indirect harms prophylaxis can induce in high-risk settings (eg, inpatient ward, intensive care unit) (8). Specifically, it has been shown (8) that inpatients undergoing 13-hour oral prophylaxis have a significantly longer hospital length of stay (median, 25 hydrocortisone administered immediately, followed by subsequent doses of 200 mg of IV hydrocortisone every 4 hours until the contrast material is administered, along with administration of 50 mg of IV diphenhydramine 1 hour before contrast material administration.…”

“…Although these data do not add information to the larger discussion about premedication efficacy in general, they may be used to conclude that a 5-hour IV regimen is at least not substantially less effective than the commonly used 13hour oral regimen. (3), we believe that the number needed to treat to prevent one reaction is likely quite high (8). In fact, one estimate of the number needed to treat to prevent one lethal reaction with 13-hour oral prophylaxis in a population of patients who have had a prior reaction to iodine-based contrast material is approximately 50 000 patients (8).…”

Gadolinium‐based contrast agents: A comprehensive risk assessment

“…While the risks associated with short corticosteroid courses are low, these agents must be used with caution in patients with uncontrolled hypertension, diabetes, and active infections . To this point, corticosteroid premedication for inpatients may prolong admission and thus increase the risk for hospital‐associated infections . Anaphylactoid reactions have also been reported with corticosteroids, most frequently with intravenous formulations…”

“…21 To this point, corticosteroid premedication for inpatients may prolong admission and thus increase the risk for hospital-associated infections. 22 Anaphylactoid reactions have also been reported with corticosteroids, most frequently with intravenous formulations. 10…”