October 31, 2011

Switching IV to pill form of drugs could save millions

Study by Johns Hopkins researchers finds potential for huge cost savings

Switching hospitalized patients able to take medication by mouth from intravenous to pill forms of the same drugs could safely save millions of dollars a year, new Johns Hopkins research suggests.

In a review of computerized records for the year 2010 at The Johns Hopkins Hospital, the researchers estimated savings of more than $1.1 million in the Department of Medicine alone—not including surgical patients—by swapping out four commonly prescribed IV medications with their oral equivalents. A report on the study is published in the journal Clinical Therapeutics.

“Our study looked at just four drugs administered by one department in one hospital in one year and found more than a million dollars in potential savings,” said Brandyn D. Lau, a medical informatics specialist at the Johns Hopkins University School of Medicine and the study’s leader. “Imagine if every hospital took a hard look at substituting oral medications for IV ones whenever possible. We’re talking about an enormous financial impact, with no risk to patients.”

According to the Centers for Medicare and Medicaid Services, roughly 12 percent of U.S. health care expenditures in 2009—$293.2 billion—were for medications and nondurable medical products.

Lau said that a large-scale switch to oral medications has the potential not only to decrease costs but also to reduce the need for puncturing veins to insert intravenous tubes or medications directly, procedures that carry a higher risk of hospital-acquired bloodstream infections and longer hospital stays. Simple reminders to physicians that their patients may be eligible to switch medication types could yield large savings, the researchers said.

The four medications reviewed in the study were chlorothiazide, used to treat high blood pressure and address fluid retention; voriconazole, an anti-fungal drug; levetiracetam, to stop seizures; and pantoprazole, for acid reflux. By combing Johns Hopkins’ computerized provider order entry system, the researchers examined whether patients receiving these drugs intravenously also were prescribed oral medications or if they were being fed solid meals, another indication that they would likely be able to swallow pills. In 2010, 10,905 doses of the four medications were given intravenously to patients admitted through the Department of Medicine. Lau said that the drugs are given even more frequently in surgery patients.

The team compared those results with the cost of the various medications. For example, the wholesale cost of a 5-milligram tablet of chlorothiazide is $1.48; an equivalent dose of the drug given intravenously is $357.24, more than 200 times as much. Pantoprazole, the most commonly administered medication in the study, is $4.09 per 40-milligram tablet, while a 40-milligram vial is $144. That medication is often given to patients several times a day. The potential cost savings per patient for the acid reflux medication would be $680.98, the researchers found.

The researchers noted that not all patients are able to switch from the intravenous to the oral form of a drug. Diet orders may change, Lau said, or a physician may have a reason for not switching a particular patient to an oral medication. But even a small increase in the conversion of patients from IV to oral medication would have a substantial financial impact due to the considerable difference in costs between the two forms. Although this research looked at only the wholesale costs of the drugs, Lau said that other costs associated with giving medication by IV could be reduced if fewer drugs were administered that way.

The researchers chose these four drugs to study because the oral and IV forms are similar, but many other drugs potentially could also be swapped out for an even greater cost savings.

To implement the swaps, Lau said, hospitals with computerized medication systems could add alerts to their programs that would appear when a patient on an IV medication meets eligibility criteria for oral medication intake. Lau cautioned, however, that doctors are already bombarded with reminders, and it might be best to start with drugs with the highest savings per dose, such as levetiracetam and chlorothiazide.

“There is a danger in overreminding,” Lau said. “Constant reminders may annoy doctors to the point where they stop paying attention. We need to study the best way to get doctors to switch from IV to oral medications.”

Education, he said, is another avenue. Teaching doctors that oral medication is a cheaper alternative to IV may encourage them to make the switch without subjecting them to regular, potentially irritating reminders.

Other Johns Hopkins researchers involved in the study are Brian L. Pinto, David R. Thiemann and Christoph U. Lehmann.