Working together, hospital pharmacists and physicians were able to save a lot of money for their health system by using alternatives to high-priced cardiovascular medications.
According to an article published in the September 7 issue of NEJM Catalyst, pharmacists and physicians at the Cleveland Clinic and its Heart and Vascular Institute developed a specific strategy to respond to the major price increases of two commonly used cardiovascular drugs, nitroprusside and isoproterenol.
Their work resulted in an impressive estimated cost savings of more than $8.5 million between 2012 and 2015. For the 12,790 patients treated with nitroprusside in that time, they saved $8,067,551, or 56% relative cost savings. The 4,074 patients treated with isoproterenol saved $581,986, or 55% relative cost savings.
Umesh Khot, MD, Vice Chairman of Cardiovascular Medicine at Cleveland Clinic, along with a pharmacist and clinicians, first targeted nitroprusside and isoproterenol because of the “greater than typical” price increases on those drugs, which, in turn, impacted pharmacy planning and budgets, Khot told Drug Topics.
Between 2012 and 2015, nitroprusside prices increased 30-fold to $880.88 for 50 mg, according to the study. Simultaneously, isoproterenol prices increased nearly 70-fold, with the average wholesale acquisition cost per milligram increasing from $26.20 to $1790.11 from 2012 through 2015.
The team identified three specific areas for therapeutic alternatives: the use of nitroglycerin instead of nitroprusside for postoperative hypertension, the use of clevidipine instead of nitroprusside for aortic dissection, and dobutamine instead of isoproterenol for intraoperative testing of myectomy patients.
“These clinical indications and therapeutic alternatives were the areas in which these alternatives where felt to be sufficiently similar in efficacy to ensure appropriate clinical care,” Khot said.
Notably, the therapeutic change decisions were not made by senior leadership of the hospital. “Instead, therapeutic alternatives were identified by pharmacists and front-line clinicians working in the particular clinical areas,” Khot said. “A strategic partnership between pharmacists and physicians can lead to an effective response to rising drug prices.”
Beyond substituting high-price drugs, the the study reported on the team’s commitment to reducing waste by stopping the routine ordering as a prechecked therapy for hypertension after cardiac surgery. They also removed the option for high-concentration nitroprusside in the electronic medication order, and lowered the routine dosage of isoproterenol from 400 to 100 mcg, “in keeping with the typical patient dose.”
According to the article, the changes were widely accepted in clinical care areas. The authors mentioned that some changes, such as the reduction in isoproterenol dispensing quantities, were met with “no resistance.” They did mention that occasional reeducation was needed to remind clinicians of the new protocols, especially in intensive care where nitroprusside use had been the norm for a long time.
The researchers have received a great amount of interest in this work because “this a very common problem that all hospitals are facing,” Khot said. “We hope our work provides a framework on how to approach this issue by protecting critical indications, reducing waste, and identifying therapeutic alternatives.”