Leveraging the Outpatient Pharmacy to Reduce Medication Waste in Pediatric Asthma Hospitalizations
BACKGROUND AND OBJECTIVE: Previous local quality improvement focused on discharging patients with inhaled corticosteroids (ICS) “in-hand” decreased healthcare reutilization after hospitalization for an asthma exacerbation. However, as a result of these new processes, some patients admitted for an asthma exacerbation received more than one ICS inhaler during their admission, contributing to medication waste and potential patient confusion regarding their discharge medication regimen. We sought to decrease this waste.
METHODS: We conducted a quality improvement project to reduce the prescribing of multiple ICS inhalers to patients at a large academic children’s hospital. Our primary outcome measure was the monthly percentage of patients admitted with an asthma exacerbation who were administered more than one ICS inhaler. A secondary outcome measure evaluated the reliability of the new process of using the hospital-based outpatient pharmacy to supply ICS “in-hand” and verify insurance coverage. After the process map review, we hypothesized a delay in the initial ICS treatment decision would allow for both a finalized discharge medication plan and a standardized process to verify outpatient insurance coverage. |
RESULTS: The mean percentage of patients receiving more than one ICS inhaler decreased from our baseline of 7.4% to 0.7%. Verification of outpatient prescription insurance coverage via the outpatient pharmacy increased from 0.7% to 50%. The average inpatient cost (average wholesale price) for ICS decreased by 62% to $90.25.
CONCLUSIONS: Our process change to use the outpatient pharmacy to dispense and verify insurance coverage for ICS medication was associated with a reduction in medication waste during admission for an asthma exacerbation.
© 2020 Society of Hospital Medicine
Cost Outcome Measure
The average cost of an ICS billed during hospitalization for an acute asthma exacerbation was $236.57 per ICS during the baseline period. After the intervention period, the average inpatient cost for ICS decreased by 62% to $90.25 per ICS (Figure 4).
Balancing Measure
DISCUSSION
Our team reduced the monthly percent of children hospitalized with an acute asthma exacerbation administered more than one ICS from 7.4% to 0.7% after implementation of a new workflow process for ordering ICS utilizing the hospital-based outpatient pharmacy. The new workflow delayed ordering and administration of the initial inpatient ICS treatment, allowing time to consider a step-up in therapy. The brief delay in initiating ICS is not expected to have clinical consequence given the concomitant treatment with systemic corticosteroids. In addition, the outpatient pharmacy was utilized to verify insurance coverage reliably prior to dispensing ICS, reducing medication waste, and discharge delays due to outpatient medication formulary conflicts.
Our hospital’s previous approach to inpatient asthma care resulted in a highly reliable process to ensure patients were discharged with medications-in-hand as part of a broader system that effectively decreased reutilization. However, the previous process inadvertently resulted in medication waste. This waste included nearly full inhalers being discarded, additional work by the healthcare team (ordering providers, pharmacists, and RTs), and unnecessary patient charges.
While the primary driver of our decision to use the outpatient pharmacy was to adjudicate insurance prescription coverage reliably to prevent waste, this change likely resulted in a financial benefit to patients. The average cost per asthma admission of an inpatient billed for ICS using the average wholesale price, decreased by 62% following our interventions. The decrease in cost was primarily driven by using patient-supplied medications, including prescriptions newly filled by the on-site outpatient pharmacy, whose costs were not captured in this measure. While our secondary measure may underestimate the total expense incurred by families for an ICS, families likely receive their medications at a lower cost from the outpatient pharmacy than if the ICS was provided by an inpatient pharmacy. The average wholesale price is not what families are charged or pay for medications, partly due to differences in overhead costs that result in inpatient pharmacies having significantly higher charges than outpatient pharmacies. In addition, the 6.7% absolute reduction of our primary measure resulted in direct savings by reducing inpatient medication waste. Our process results in 67 fewer wasted ICS devices ($15,960) per 1,000 admissions for asthma exacerbation, extrapolated using the average cost ($238.20, average wholesale price) of each ICS during the baseline period.
Our quality improvement study had several limitations. (1) The interventions occurred at a single center with an established culture that embraces quality improvement, which may limit the generalizability of the work. (2) Our process verified insurance coverage with a hospital-based outpatient pharmacy. Some ICS prescriptions continued to be dispensed from the inpatient pharmacy, limiting our ability to verify insurance coverage. Local factors, including regulatory restrictions and delivery requirements, may limit the generalizability of using an outpatient pharmacy in this manner. (3) We achieved our goal of decreasing medication waste, but our a priori goal was to maintain our commitment to our established practice of interactive patient education with an ICS device as well as medications-in-hand at time of discharge. Our balancing measure showed a decrease in the percent of patients with a discharge prescription for an ICS who also received an inpatient dose of that ICS. This implies a decreased fidelity in our previously established education protocols. We had postulated that this occurred when the patient-supplied medication arrived on the day of discharge, but not close to when the medication was scheduled on the medication administration report, preventing administration. However, this is not a direct measure of patients receiving medications-in-hand or interactive medication education. Both may have occurred without administration of the ICS. (4) Despite a hospital culture that embraces quality improvement, this project required a significant change in the workflow that required considerable education at the time of implementation to integrate the new process reliably. However, once the process was in place, we have been able to sustain our improvement with limited educational investment.
