Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

Abstract

A framework for evaluating pharmacists’ impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence‐to‐decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.

Benefit of Incorporating Clinical Pharmacists in an Adult Intensive Care Unit: A Cost‐saving Study

“…A framework proposed in a recent study was adopted to classify and assess the value of clinical pharmacist interventions in ICUs 12 . Pharmacist interventions were grouped into six main categories: (a) prevention of adverse drug events (ADEs), identified as actions to prevent major ADEs, including inappropriate dosage affecting efficacy or safety, duplication of therapy and drugs prescribed to incorrect patient, as well as to prevent minor ADEs, including minor duplication of therapy, minor drug‐drug, drug‐food or drug‐laboratory interaction, and incorrect patient information (eg weight or age); these actions taken by the pharmacist could prevent temporary or permanent patient harm that may lead to increased length of stay as well as other medical complications due to a medication error or reaction; (b) resource utilization, identified as actions to prevent unnecessary care, avoid unnecessary laboratory tests, switch from intravenous to oral medication route, optimize medication therapy through discontinuation of unwarranted therapy and preventing unnecessary high‐cost medications; (c) individualization of patient care, identified as tailoring medication through dosage adjustment, antibiotic streamlining, new drug therapy recommendations, anticoagulation management and pharmacokinetic monitoring; (d) prophylaxis, identified as reducing the risk of complications in critically ill patients by initiating venous thromboembolism prophylaxis, reducing stress‐related mucosal bleeding, and preventing ventilator‐associated pneumonia; (e) hands‐on care, which involves a broad range of interventions such as bedside interventions not captured by other categories, including participated in emergency blue codes and rapid response teams, educating patients on medication at discharge and following up with patients after discharge; and (f) administrative and supportive tasks, identified as activities of direct patient care that are more administrative or supportive in nature which aim to improve the medication use process.…”

“…All considered costs were calculated based on acquisition costs. For each category, the average cost reported in a scoping review of landmark studies was assumed 12 . This scoping review by Hammond et al is the most recent study to identify, aggregate and qualitatively define quality evidence of cost avoidance made by clinical pharmacists on interventions performed in an ICU or emergency department.…”

“…Table 1 includes all costs avoided per intervention and sub‐type for each of the six categories considered. The monetary values assigned to pharmacist interventions in this investigation were those used in the Hammond study 12 adjusted to 2020 US dollars according to the Bureau of Labor Statistics consumer price index.…”

Drs. Haas and Vermeulen reply to Drs. Hammond and Rech

“…As we indicated previously, the scoping review from Pharmacotherapy showed that 33 of the 38 intervention categories of cost avoidance were supported by very low rigor sources, including expert opinion sources (level IV evidence) and by descriptive, noncomparative articles (level III evidence). 3 Neither of those types of evidence have any credibility when attempting to justify investment in clinical pharmacy services. The notion that data from these sources represent "almost exact cost avoidance" as suggested by Hammond and Rech in their letter, is simply ridiculous hyperbole.…”

Prevention Strategies to Improve Outcomes in Critically Ill Adults

“…Preventing untoward complications and adverse drug effects is a concern of all clinicians from the standpoint of patient outcomes but also with regard to health care costs. A unique article included in this themed issue provides a framework for mitigating costs by introducing strategies for pharmacists, or really any clinician, to document their worth on the basis of cost avoidance. Of note, cost‐avoidance interventions should not be the responsibilities of a particular profession but a responsibility of the health care team.…”