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A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU
Holly Catherine Gillis1, Kevin Dolan2, Cheryl L Sargel3
1Department of Anesthesiology, The Ohio State University College of Medicine, Columbus Ohio.
Insights
Implementing a value-based clinical pathway significantly reduced dornase alfa use in critically ill children, improving healthcare value without adverse effects. This strategy optimized mucolytic costs by prioritizing evidence-based, lower-cost alternatives.
Area of Science:
- Pediatric Critical Care Medicine
- Health Economics
- Clinical Pathway Development
Background:
- High-cost medications without evidence reduce healthcare value.
- Dornase alfa use in critically ill, mechanically ventilated children lacked supporting evidence.
- Reducing unnecessary dornase alfa utilization was the primary objective.
Purpose of the Study:
- To decrease dornase alfa utilization in critically ill pediatric patients.
- To implement a value-based clinical pathway for mucolytic selection.
- To improve healthcare value by optimizing medication use.
Main Methods:
- An observational pre-post design was used in a quaternary pediatric intensive care unit.
- A clinical pathway guided mucolytic choice, favoring hypertonic saline and N-acetylcysteine over dornase alfa.
- Interventions included physician education and pathway rollout; control charts monitored orders.
Main Results:
- Dornase alfa starts decreased by 53% and total doses by 75% per 100 patient days.
- Use of hypertonic saline and N-acetylcysteine increased, with no adverse effects noted.
- Mucolytic costs reduced by 59% ($2183.08 to $885.77 per 100 patient days).
Conclusions:
- A clinical pathway prioritizing pharmacoeconomics improved healthcare value.
- Evidence-based medication selection enhanced patient care without negative outcomes.
- Value-based pathways are effective for optimizing high-cost medication use.
Introduction:
High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children.
Methods:
The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders.
Results:
New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD).
Conclusion:
A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.
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