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Savadjian AJ, Taicher BM, La JO, Podgoreanu M, Miller TE, McCartney S, Raghunathan K, Shah N, Mamoun N. Reduce intraoperative albumin utilisation in cardiac surgical patients: a quality improvement initiative. BMJ Open Qual 2024; 13:e002726. [PMID: 38663929 PMCID: PMC11043756 DOI: 10.1136/bmjoq-2023-002726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest intraoperative albumin users during cardiac surgery. Therefore, we designed a quality improvement project (QIP) to introduce a bundle of interventions to reduce intraoperative albumin use in cardiac surgical patients. METHODS Our institutional MPOG data were used to analyse the FLUID-01-C measure that provides the number of adult cardiac surgery cases where albumin was administered intraoperatively by anaesthesiologists from 1 July 2019 to 30 June 2022. The QIP involved introduction of the following interventions: (1) education about appropriate albumin use and indications (January 2021), (2) email communications reinforced with OR teaching (March 2021), (3) removal of albumin from the standard pharmacy intraoperative medication trays (April 2021), (4) grand rounds presentation discussing the QIP and highlighting the interventions (May 2021) and (5) quarterly provider feedback (starting July 2021). Multivariable segmented regression models were used to assess the changes from preintervention to postintervention time period in albumin utilisation, and its total monthly cost. RESULTS Among the 5767 cardiac surgery cases that met inclusion criteria over the 3-year study period, 16% of patients received albumin intraoperatively. The total number of cases that passed the metric (albumin administration was avoided), gradually increased as our interventions went into effect. Intraoperative albumin utilisation (beta=-101.1, 95% CI -145 to -56.7) and total monthly cost of albumin (beta=-7678, 95% CI -10712 to -4640) demonstrated significant decrease after starting the interventions. CONCLUSIONS At a single academic cardiac surgery programme, implementation of a bundle of simple and low-cost interventions as part of a coordinated QIP were effective in significantly decreasing intraoperative use of albumin, which translated into considerable costs savings.
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Affiliation(s)
- André J Savadjian
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Brad M Taicher
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Jong Ok La
- Duke Molecular Physiology Institute, Duke University Hospital, Durham, North Carolina, USA
| | - Mihai Podgoreanu
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Timothy E Miller
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Sharon McCartney
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | | | - Nirav Shah
- University of Michigan, Ann Arbor, Michigan, USA
| | - Negmeldeen Mamoun
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
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Forster CM, Halls S, Allarakhia S, Modi D, Chung W, Derry K, Digby G, Flemming J, McGugan J, Mackulin H, Montague S, Sibley S, Silver SA, Sirosky-Yanyk A, Stevens A, de Wit K, Zhang L, Callum J. Improving appropriate use of intravenous albumin: results of a single-centre audit and multifaceted intervention. BMJ Open Qual 2024; 13:e002534. [PMID: 38626937 PMCID: PMC11029189 DOI: 10.1136/bmjoq-2023-002534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Intravenous albumin has limited indications supported by randomised controlled trials, yet it is often prescribed for indications not supported by evidence. AIM To reduce unnecessary transfusion of albumin. INTERVENTIONS Under the leadership of a multidisciplinary quality improvement team, evidence-based recommendations were disseminated in tandem with a new electronic order set, an educational strategy, qualitative interviews with prescribers and a return policy change to reduce wastage. IMPLEMENTATION AND EVALUATION Interventions were introduced in a staggered fashion. The primary outcome, appropriate use of albumin, was monitored and quantified using pre-intervention and post-intervention audits. Process measures included statistical process run charts of monthly usage of 5% and 25% albumin and wastage. Data on length of stay (hospital and intensive care), new inpatient starts on kidney replacement and mortality were collected as balancing measures. RESULTS Appropriate albumin usage based on indication increased from 30% to 50% (p<0.0001). There was significantly less overall albumin usage in the post-intervention period compared with the pre-intervention period (negative coefficient, p<0.0001), driven by a major reduction in the utilisation of the 5% formulation (p<0.0001). Overall albumin usage was significantly lower in the post-intervention period, decreasing from 800 to 450 vials per month. The intervention resulted in significantly less wastage (negative coefficient, p=0.017). Mortality, length of stay and new starts on kidney replacement therapy remained constant throughout the study period. CONCLUSION Improved prescribing of albumin was achieved with a multifaceted approach. Substantial and sustained reductions in usage were achieved without negatively impacting patient-important outcomes. The estimated annual savings for the purchase cost of albumin was CAN $300 000. We provide a structured process for other organisations to optimise their use of albumin.
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Affiliation(s)
- Corey M Forster
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | | | - Dimpy Modi
- Department of Medicine, Hamilton, Stockholm, Ontario, Sweden
| | - Wiley Chung
- Surgery, Queen's University, Kingston, Ontario, Canada
| | - Kendra Derry
- Department of Anesthesiology, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jennifer Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John McGugan
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Heather Mackulin
- Nursing, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Steven Montague
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Samuel A Silver
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Angela Sirosky-Yanyk
- Transfusion Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Andrew Stevens
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Liying Zhang
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jeannie Callum
- Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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3
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King AJ, Tang L, Davis BS, Preum SM, Bukowski LA, Zimmerman J, Kahn JM. Machine learning-based prediction of low-value care for hospitalized patients. INTELLIGENCE-BASED MEDICINE 2023; 8:100115. [PMID: 38130744 PMCID: PMC10735238 DOI: 10.1016/j.ibmed.2023.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Objective Low-value care (i.e., costly health care treatments that provide little or no benefit) is an ongoing problem in United States hospitals. Traditional strategies for reducing low-value care are only moderately successful. Informed by behavioral science principles, we sought to use machine learning to inform a targeted prompting system that suggests preferred alternative treatments at the point of care but before clinicians have made a decision. Methods We used intravenous administration of albumin for fluid resuscitation in intensive care unit (ICU) patients as an exemplar of low-value care practice, identified using the electronic health record of a multi-hospital health system. We divided all ICU episodes into 4-h periods and defined a set of relevant clinical features at the period level. We then developed two machine learning models: a single-stage model that directly predicts if a patient will receive albumin in the next period; and a two-stage model that first predicts if any resuscitation fluid will be administered and then predicts albumin only among the patients with a high probability of fluid use. Results We examined 87,489 ICU episodes divided into approximately 1.5 million 4-h periods. The area under the receiver operating characteristic curve was 0.86 for both prediction models. The positive predictive value was 0.21 (95% confidence interval: 0.20, 0.23) for the single-stage model and 0.22 (0.20, 0.23) for the two-stage model. Applying either model in a targeted prompting system could prevent 10% of albumin administrations, with an attending physician receiving one prompt every 4.2 days of ICU service. Conclusion Prediction of low-value care is feasible and could enable a point-of-care, targeted prompting system that offers suggestions ahead of the moment of need before clinicians have already decided. A two-stage approach does not improve performance but does interject new levers for the calibration of such a system.
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Affiliation(s)
- Andrew J. King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sarah M. Preum
- Department of Computer Science, Dartmouth College, Hanover, NH, USA
| | - Leigh A. Bukowski
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John Zimmerman
- Human-Computer Interaction Institute, Carnegie Mellon University School of Computer Science, Pittsburgh, PA, USA
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Altawalbeh SM, Almestarihi EM, Khasawneh RA, Momany SM, Ababneh MA, Shawaqfeh MS. Clinical and economic outcomes associated with intravenous albumin fluid use in the intensive care unit: a retrospective cohort study. Expert Rev Pharmacoecon Outcomes Res 2023; 23:789-796. [PMID: 37191454 DOI: 10.1080/14737167.2023.2215431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/15/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES This study was undertaken to evaluate the prescribing practice of albumin in the intensive care unit (ICU) and to compare the clinical and economic outcomes associated with intravenous (IV) albumin compared to crystalloids in the ICU. METHODS This was a retrospective cohort study of ICU adult patients admitted to King Abdullah University Hospital during 2018-2019. Patient demographics, clinical characteristics, and admission charges were retrieved from medical records and billing system. Survival analysis, multivariable regression models, and propensity score matching estimator were performed to evaluate the impact of IV resuscitation fluid types on the clinical and economic outcomes. RESULTS Albumin administration in the ICU was associated with significantly lower hazards of ICU death (HR = 0.57; P value <0.001), but without improving overall death probability compared to crystalloids. Albumin was associated with significant prolongation in the ICU length of stay (5.86 days; P value <0.001). Only 88 patients (24.3%) were prescribed albumin for Food and Drug Administration (FDA)-approved indications. Admission charges were significantly higher for patients treated with albumin (p value <0.001). CONCLUSIONS IV Albumin use in the ICU was not associated with significant improvement in clinical outcomes, but with a remarkable increase in economic burden. The majority of patients received albumin for non-FDA-approved indications.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Eman M Almestarihi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Rawand A Khasawneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Suleiman Mohammad Momany
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammad S Shawaqfeh
- Department of pharmacy practice, College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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5
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Ullah A, Kwon HT, Lim SI. Albumin: A Multi-talented Clinical and Pharmaceutical Player. BIOTECHNOL BIOPROC E 2022. [DOI: 10.1007/s12257-022-0104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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6
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Zhang X, Zhang L, Wei C, Feng L, Yang J, Zhang G, Lu G, Gui X, Zhou Y, Yang K, Zhou J, Zhou X, Wang R, Chen S, Ji Y. U-shaped association between serum albumin and pediatric intensive care unit mortality in critically ill children. Front Nutr 2022; 9:931599. [PMID: 36110400 PMCID: PMC9468926 DOI: 10.3389/fnut.2022.931599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The detailed association between albumin levels and mortality has not been studied in critically ill children. The aim of this study was to reveal an association between albumin levels in detail and mortality in critically ill children. Materials and methods We retrospectively collected data from children admitted to four pediatric intensive care units (PICUs) in China between January 2015 and October 2020. Restricted cubic spline curves based on logistic regression models were generated to evaluate the detailed associations between serum albumin levels and PICU mortality. Threshold effect analysis was performed using two piecewise regression models. Results The study included 9,123 children. The overall mortality was 5.3%. The detailed association between serum albumin levels and the risk of mortality followed a U-shape. The risk of mortality decreased with increasing serum albumin levels (OR = 0.919; 95% CI: 0.886, 0.954) in children with serum albumin levels < 43.2 g/L and increased with increasing serum albumin levels (OR = 1.174; 95% CI: 1.044, 1.316) in children with serum albumin levels ≥ 43.2 g/L. Conclusion There was a U-shaped association between serum albumin levels and mortality in critically ill children in the PICU.
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Affiliation(s)
- Xuepeng Zhang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
- Department of Critical Care Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Lifan Zhang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Canzheng Wei
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
- Department of Critical Care Medicine, The Second Affiliated Hospital of Shandong First Medical University, Tai’an, China
| | - Liwei Feng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Juqin Yang
- Biobank, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Guoyan Lu
- Department of Pediatric Critical Care Medicine, West China Women’s and Children’s Hospital, Sichuan University, Chengdu, China
| | - Xiying Gui
- Department of Critical Care Medicine, People’s Hospital of Tibet Autonomous Region, Lhasa, China
| | - Yue Zhou
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Kaiying Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jiangyuan Zhou
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xinle Zhou
- Department of Pediatric Critical Care Medicine, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, China
| | - Ruoran Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Siyuan Chen
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Siyuan Chen,
| | - Yi Ji
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
- Yi Ji,
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7
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Podgoreanu MV, Mamoun N. Albumin vs Crystalloid Fluid for Resuscitation in Cardiac Surgery: New Evidence and Arguments in the Timeless Debate. JAMA 2022; 328:246-248. [PMID: 35852542 DOI: 10.1001/jama.2022.10113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mihai V Podgoreanu
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Negmeldeen Mamoun
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
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8
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Lin TK, Werner K, Witter S, Alluhidan M, Alghaith T, Hamza MM, Herbst CH, Alazemi N. Individual performance-based incentives for health care workers in Organisation for Economic Co-operation and Development member countries: a systematic literature review. Health Policy 2022; 126:512-521. [DOI: 10.1016/j.healthpol.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/04/2022]
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9
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Ibrahim DM, Shawki MA, Solayman MH, Sabri NA. The Impact of Clinical Pharmacist Implemented Protocol on Albumin Utilization and Cost in an Intensive Care Unit in Egypt. Front Pharmacol 2022; 13:825048. [PMID: 35370698 PMCID: PMC8971523 DOI: 10.3389/fphar.2022.825048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Albumin is an expensive non-blood plasma substitutes with limited availability that has been reported to be inappropriately used in healthcare settings. Hence, interventions are recommended to control its misuse.Objective: To evaluate the impact of clinical pharmacist implemented dispensing protocol on optimization of albumin use in an intensive care unit (ICU).Design: A retrospective prospective 3-phase interventional study was conducted in an ICU in a tertiary Egyptian hospital over a period of 2 years.Methods: The study included three phases; a preparation phase where a local albumin dispensing protocol and a restriction dispensing form were prepared by clinical pharmacists and was approved by the local Drugs and Therapeutics Committee, a retrospective pre-implementation phase in which the medical records of all ICU patients receiving albumin were evaluated for appropriateness of albumin use according to the developed protocol, and a prospective implementation phase where the dispensing protocol and restriction dispensing form were applied. The pattern of albumin consumption and cost were recorded and compared between the retrospective and prospective phases.Results: In the retrospective phase, 190 ICU patients received albumin of whom 83.6% was considered inappropriate indications for albumin compared to only 44 patients in the prospective phase of whom 16% was considered inappropriate (p-value <0.001). Clinical pharmacists’ interventions significantly decreased the inappropriate albumin consumption from 4.7 vials/patient in the retrospective phase to 2.7 vials/patient in the prospective phase (p-value <0.001) with a total cost savings of 313,900 Egyptian Pounds (19,930 US Dollars).Conclusion: The current study showed that clinical pharmacists’ interventions led to a significant control on albumin use and consequently reduced the cost associated with its consumption.
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Affiliation(s)
| | - May Ahmed Shawki
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
- *Correspondence: May Ahmed Shawki,
| | | | - Nagwa Ali Sabri
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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10
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Auld SC, Harrington KRV, Adelman MW, Robichaux CJ, Overton EC, Caridi-Scheible M, Coopersmith CM, Murphy DJ. Trends in ICU Mortality From Coronavirus Disease 2019: A Tale of Three Surges. Crit Care Med 2022; 50:245-255. [PMID: 34259667 PMCID: PMC8796834 DOI: 10.1097/ccm.0000000000005185] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the association between time period of hospitalization and hospital mortality among critically ill adults with coronavirus disease 2019. DESIGN Observational cohort study from March 6, 2020, to January 31, 2021. SETTING ICUs at four hospitals within an academic health center network in Atlanta, GA. PATIENTS Adults greater than or equal to 18 years with coronavirus disease 2019 admitted to an ICU during the study period (i.e., Surge 1: March to April, Lull 1: May to June, Surge 2: July to August, Lull 2: September to November, Surge 3: December to January). MEASUREMENTS AND MAIN RESULTS Among 1,686 patients with coronavirus disease 2019 admitted to an ICU during the study period, all-cause hospital mortality was 29.7%. Mortality differed significantly over time: 28.7% in Surge 1, 21.3% in Lull 1, 25.2% in Surge 2, 30.2% in Lull 2, 34.7% in Surge 3 (p = 0.007). Mortality was significantly associated with 1) preexisting risk factors (older age, race, ethnicity, lower body mass index, higher Elixhauser Comorbidity Index, admission from a nursing home); 2) clinical status at ICU admission (higher Sequential Organ Failure Assessment score, higher d-dimer, higher C-reactive protein); and 3) ICU interventions (receipt of mechanical ventilation, vasopressors, renal replacement therapy, inhaled vasodilators). After adjusting for baseline and clinical variables, there was a significantly increased risk of mortality associated with admission during Lull 2 (relative risk, 1.37 [95% CI = 1.03-1.81]) and Surge 3 (relative risk, 1.35 [95% CI = 1.04-1.77]) as compared to Surge 1. CONCLUSIONS Despite increased experience and evidence-based treatments, the risk of death for patients admitted to the ICU with coronavirus disease 2019 was highest during the fall and winter of 2020. Reasons for this increased mortality are not clear.
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Affiliation(s)
- Sara C Auld
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kristin R V Harrington
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Chad J Robichaux
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
| | | | - Mark Caridi-Scheible
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Craig M Coopersmith
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David J Murphy
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
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11
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Dale CM, Rose L, Carbone S, Pinto R, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Scales DC, Cuthbertson BH. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial. Intensive Care Med 2021; 47:1295-1302. [PMID: 34609548 PMCID: PMC8490143 DOI: 10.1007/s00134-021-06475-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Purpose Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06475-2.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, Room 1.1.3, London, SE1 8WA, UK.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Krembil Research Institute, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
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12
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Buckley MS, Agarwal SK, Lansburg JM, Kopp BJ, Erstad BL. Clinical Pharmacist–Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients. Ann Pharmacother 2020; 55:44-51. [DOI: 10.1177/1060028020935575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. Objective: To evaluate the clinical and economic impact of a clinical pharmacist–led intervention strategy targeting inappropriate albumin use in general ward patients. Methods: A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist–led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. Results: A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% ( P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively ( P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use. Conclusion and Relevance: Clinical pharmacist–led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.
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Affiliation(s)
| | | | | | - Brian J. Kopp
- Banner—University Medical Center Tucson, Tucson, AZ, USA
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13
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Buckley MS, Erstad BL, Lansburg JM, Agarwal SK. Hyperoncotic Albumin Reduces Net Fluid Loss Associated With Hemodialysis. Hosp Pharm 2020; 55:130-134. [PMID: 32214448 DOI: 10.1177/0018578719828331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The purpose of this study was to compare the volume of fluid removal associated with and without 25% albumin administration in conjunction with hemodialysis. Methods: This retrospective, cohort study was conducted at a large academic medical center over a 6-month period to compare the net fluid amount removed (mL) during hemodialysis between patients administered 25% albumin and those without albumin. Results: A total of 238 patients consisting of 973 unique hemodialysis sessions were evaluated. The mean overall net fluid removed by hemodialysis in the 25% albumin and no albumin groups were 1242 mL and 1899 mL, P < .001, respectively. No albumin group had significantly higher mean fluid losses compared with 25% albumin for a total dose of either 25 g (P = .001) or 50 g (P = .001). There were no significant differences in mean fluid loss between the no albumin group and patients receiving 75 g or 100 g of albumin. Post hoc analysis failed to demonstrate a dose-dependent response in those patients receiving 25% albumin and no albumin. Conclusion: Hyperoncotic albumin administered during hemodialysis sessions reduced net fluid loss associated with hemodialysis. The findings of this study do not support the routine use of 25% albumin to improve fluid removal during dialysis.
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14
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Buckley MS, Knutson KD, Agarwal SK, Lansburg JM, Wicks LM, Saggar RC, Richards EC, Kopp BJ, Erstad BL. Clinical Pharmacist-Led Impact on Inappropriate Albumin Use and Costs in the Critically Ill. Ann Pharmacother 2019; 54:105-112. [PMID: 31544470 DOI: 10.1177/1060028019877471] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background:Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use (P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively (P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist-led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes.
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Affiliation(s)
| | | | - Sumit K Agarwal
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Jake M Lansburg
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Laura M Wicks
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Rajeev C Saggar
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | | | - Brian J Kopp
- Banner - University Medical Center Tucson, Tucson, AZ, USA
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15
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Stelfox HT, Bourgault AM, Niven DJ. De-implementing low value care in critically ill patients: a call for action-less is more. Intensive Care Med 2019; 45:1443-1446. [PMID: 31396643 DOI: 10.1007/s00134-019-05694-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Alberta Health Services, Alberta, Canada.
| | - Annette M Bourgault
- College of Nursing, Academic Health Sciences Center, University of Central Florida, Orlando, FL, USA
- Orlando Health, Orlando, FL, USA
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Health Services, Alberta, Canada
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16
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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Udeh CI, Wanek M, Udeh BL, Hata JS. Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units. Hosp Pharm 2019; 55:154-162. [PMID: 32508352 DOI: 10.1177/0018578719828341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.
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18
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Altawalbeh SM, Abu-Su'Ud R, Alefan Q, Momany SM, Kane-Gill SL. Evaluating intensive care unit medication charges in a teaching hospital in Jordan. Expert Rev Pharmacoecon Outcomes Res 2019; 19:561-567. [PMID: 30663452 DOI: 10.1080/14737167.2019.1571413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Intensive Care Unit (ICU) medication costs contribute to a large portion of the total ICU costs. Evaluating ICU drug expenditures is essential for optimal resource use especially in countries with limited resources. Considering the dearth of data regarding ICU medication expenses in the Middle East, we sought to evaluate ICU medication charges at a large academic hospital in Jordan. Methods: ICU drug charges were extracted from the hospital administration database at King Abdullah University Hospital for 2014-2015 fiscal years (FYs). ICU drug charges were compared to non-ICU drug charges that were incurred during the same patient admissions. ICU medications with the most significant charges were identified. The most frequent diagnoses with the highest ICU medication charges were described. Results: Average ICU medication charges per day were approximately twice that of non-ICU medication charges ($121.5 versus $55.7 in 2014 and $100.2 versus $52.2 in 2015; p < 0.001 in both FYs). Meropenem and human albumin were the most expensive ICU medications. Drug charge allocation was most expensive for sepsis, motor vehicle accidents and respiratory failure. Conclusion: Drug charges in the ICU are considerably higher than non-ICU drug charges, thus requiring more vigilant cost containment approaches. Further research is needed to evaluate the appropriateness of expensive ICU medications.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology , Irbid , Jordan
| | - Rawan Abu-Su'Ud
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology , Irbid , Jordan
| | - Qais Alefan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology , Irbid , Jordan
| | - Suleiman Mohammad Momany
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology , Irbid , Jordan
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh , Pittsburgh , PA , USA
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19
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Fink RJ, Young A, Yanez ND, Hom M, Mai J, Treggiari M, Merkel M. Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit. Pharmacotherapy 2018; 38:1241-1249. [DOI: 10.1002/phar.2195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ryan J. Fink
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | | | - N. David Yanez
- OHSU/PSU School of Public Health Oregon Health & Science University Portland Oregon
| | - Marissa Hom
- Pharmaceutical Services University of California, San Francisco Medical Center San Francisco California
| | - Jennifer Mai
- Department of Pharmacy Services Oregon Health & Science University Portland Oregon
| | - Miriam Treggiari
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | - Matthias Merkel
- Anesthesiology & Perioperative Medicine Knight Cardiovascular Institute Oregon Health & Science University Portland Oregon
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20
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Cobb A, Thornton L. Hyperinflation of Nitroprusside. J Pharm Pract 2018; 31:382-389. [PMID: 30071785 DOI: 10.1177/0897190018762182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sodium nitroprusside (SNP) is a generically available and rapid-acting intravenous (IV) vasodilator that has been used clinically for decades. Prior to 2013, the cost of SNP was relatively low, and SNP was an affordable option for the treatment of acute hypertension. However, from 2013 to 2017, average wholesale prices for SNP rose to as high as $900 per vial, earning the drug its status as a "hyperinflation drug." Hyperinflation drugs such as SNP pose a significant challenge for pharmacy departments. A multidisciplinary effort involving stakeholders from many backgrounds, including pharmacists, physicians, and nurses, is key to developing an effective plan to address the problem. A therapeutic interchange, wherein a drug with similar efficacy is substituted for another, is often an appropriate strategy in this scenario. Fortunately, alternative drugs with a solid evidence base exist for the management of acute hypertension. The dihydropyridine calcium channel blockers, clevidipine and nicardipine, are IV titratable antihypertensive agents with favorable pharmacokinetic and safety profiles. Various studies indicate that clevidipine and nicardipine are effective alternatives to SNP for indications including hypertensive crisis and postoperative hypertension. Some hospitals have reported significant cost savings without adverse outcomes by substituting clevidipine or nicardipine for SNP. This article is intended to serve as a review of the evidence for clevidipine and nicardipine as potential substitutes for SNP and to provide strategies to successfully implement this therapeutic interchange.
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Affiliation(s)
- Alex Cobb
- 1 St. John Medical Center, Tulsa, OK, USA
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21
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Vazin A, Karimzadeh I, Karamikhah R, Oveisi Z, Mohseni S, Keykhaee M, Roshanfard F, Sabet E, Zargari-Samadnejad A. Clinical and economical impacts of guideline implementation by the pharmaceutical care unit for high cost medications in a referral teaching hospital. BMC Health Serv Res 2018; 18:815. [PMID: 30355286 PMCID: PMC6201544 DOI: 10.1186/s12913-018-3627-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/15/2018] [Indexed: 12/01/2022] Open
Abstract
Background Irrational drug use is a global health challenge in all healthcare settings, such as hospitals. This study evaluated the impact of an intervention by the pharmaceutical care unit on the use pattern of high-value medications and their direct costs in a referral hospital. Methods This interventional, prospective study was carried out in clinical wards of Namazi Hospital (Shiraz University of Medical Sciences) during six months from May 2015 to October 2015. Clinical pharmacists completed the checklists for albumin, intravenous (IV) pantoprazole, and IV immune globulin (IVIG), as three high-cost medications. When ordering these medications, the physicians were asked to complete the checklists. Then, trained pharmacists examined the checklists, based on the clinical and paraclinical conditions. Results The total number of administered medications and their relative cost decreased by 50.76% through guideline implementation; the difference was significant (P < 0.001). In addition, the direct cost of albumin and IV pantoprazole significantly decreased (55.8% and 83.92%, respectively). In contrast, the direct cost of IVIG increased by 40.9%. After guideline implementation, the monthly direct cost of all three medications decreased by $77,720 (55.88%). The all-cause in-hospital mortality rate did not change significantly due to the intervention. The median length of hospital stay was six and seven days, respectively in the pre- and post-intervention periods. Conclusion Based on the findings, implementation of guidelines by the pharmaceutical care unit caused a significant reduction in albumin and IV pantoprazole consumption and reduced their direct costs in a referral center in Iran. Electronic supplementary material The online version of this article (10.1186/s12913-018-3627-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Razieh Karamikhah
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Oveisi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samaneh Mohseni
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Keykhaee
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Roshanfard
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elaheh Sabet
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asal Zargari-Samadnejad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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23
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Johnk SR, Grindeland CJ, Leedahl DD, Carson PJ, Leedahl ND. Impact of a multicenter stewardship-targeted carbapenem justification requirement on the use of carbapenems in 23 hospitals. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sydney R. Johnk
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | | | - David D. Leedahl
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | - Paul J. Carson
- Department of Infectious Diseases; Sanford Medical Center; Fargo North Dakota
| | - Nathan D. Leedahl
- Department of Enterprise Pharmacy; Sanford Medical Center; Fargo North Dakota
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24
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Castillo AM, Natkowski J, Rubal-Peace G. Assessing adherence to current national guidelines for appropriate albumin use at an academic medical center. Pharm Pract (Granada) 2018; 16:1190. [PMID: 30023030 PMCID: PMC6041205 DOI: 10.18549/pharmpract.2018.02.1190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/06/2018] [Indexed: 12/29/2022] Open
Abstract
Objective: To assess adherence to current national guidelines for appropriate albumin use at an academic medical center. Methods: This retrospective chart review of 150 randomly selected patients prescribed and administered at least one dose of albumin was conducted in an urban academic medical center to evaluate the adherence of albumin orders to current national guidelines. Inclusion criteria consisted of discharged patients at least 18-years-old admitted to the intensive care unit or medical/surgical unit from September 1, 2015 to August 31, 2016. The primary outcome was the number of patients who inappropriately received albumin based on national guidelines and FDA approved indications. Secondary outcomes included the number of patients who received the incorrect concentration or dose of albumin based on indication, as well as the cost associated with inappropriate albumin prescribing. Descriptive statistics were used to report outcomes. Results: There were 68 instances (45%) where albumin was prescribed inappropriately according to guideline recommendations. Of the 82 instances where albumin was used appropriately, 18 patients received an incorrect dose (22%), and 6 received the inappropriate concentration of albumin (7%). The cost for the 150 patients included in the study associated with inappropriate albumin prescribing was approximately $13,000. Conclusions: This study identified areas for pharmacist intervention to ensure appropriate albumin utilization, as well as proper dosing for the most frequently incorrectly dosed indications, including hepato-renal syndrome, spontaneous bacterial peritonitis, and paracentesis. This study also identified an unexpected indication with significant inappropriate albumin utilization, perioperative hypotension, which is an area for further intervention to monitor and decrease use.
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Affiliation(s)
- Angelina M Castillo
- Clinical Inpatient Pharmacist. The Hospitals of Providence - East Campus. El Paso, TX (United States).
| | - Jamie Natkowski
- Clinical Pharmacist - Intensive Care. Banner University Medical Center South. Tucson, AZ (United States).
| | - Georgina Rubal-Peace
- Pharmacy Program Coordinator, Residency Program Director. Banner University Medical Center South. Tucson, AZ (United States).
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25
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Cobb A, Thornton L. Sodium Nitroprusside as a Hyperinflation Drug and Therapeutic Alternatives. J Pharm Pract 2018; 31:374-381. [PMID: 29938566 DOI: 10.1177/0897190018776396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sodium nitroprusside (SNP) is a generically available and rapid-acting intravenous (IV) vasodilator that has been used clinically for decades. Prior to 2013, the cost of SNP was relatively low, and SNP was an affordable option for the treatment of acute hypertension. However, from 2013 to 2017, average wholesale prices for SNP rose to as high as US$900 per vial, earning the drug its status as a "hyperinflation drug." Hyperinflation drugs pose a significant challenge for pharmacy departments. A multidisciplinary effort involving stakeholders from many backgrounds, including pharmacists, physicians, and nurses, is key to developing an effective cost containment strategy. A therapeutic interchange, wherein a drug with similar efficacy is substituted for another, is often an appropriate strategy to address rising drug costs. Fortunately, alternative drugs with a solid evidence base exist for the management of acute hypertension. The dihydropyridine calcium channel blockers, clevidipine and nicardipine, are IV titratable antihypertensive agents with favorable pharmacokinetic and safety profiles. Various studies indicate that clevidipine and nicardipine are effective alternatives to SNP for indications including hypertensive crisis and postoperative hypertension. Some hospitals have reported significant cost savings without adverse outcomes by substituting clevidipine or nicardipine for SNP. This article is intended to serve as a review of the evidence for clevidipine and nicardipine as potential substitutes for SNP and to provide strategies to successfully implement this therapeutic interchange.
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Affiliation(s)
- Alex Cobb
- 1 St John Medical Center, Tulsa, OK, USA
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26
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Ishida TS, Sakai MC, Melo DOD. The appropriate use of human albumin in a Brazilian University Hospital: therapeutic indication and dosage regimen. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000418008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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27
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Kerlin MP, Halpern SD. Changing Intensivists' Behaviors: A Challenge in Need of New Solutions. Am J Respir Crit Care Med 2017; 196:2-4. [PMID: 28665202 DOI: 10.1164/rccm.201701-0020ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Meeta Prasad Kerlin
- 1 Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania and
| | - Scott D Halpern
- 1 Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania and.,2 Palliative and Acute Illness Research Center University of Pennsylvania Philadelphia, Pennsylvania
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28
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Laki B, Taghizadeh-Ghehi M, Assarian M, Heidari K, Torkamandi H, Javadi MR, Gholami K. Effect of hospital-wide interventions to optimize albumin use in a tertiary hospital. J Clin Pharm Ther 2017; 42:704-709. [PMID: 28597926 DOI: 10.1111/jcpt.12566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/02/2017] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Albumin has been frequently used as a therapeutic agent based on previous recommendations that are mostly controversial. Considering limited evidence-based indications, common inappropriate albumin use in many hospitals necessitates prompt educational and regulatory interventions. We performed this study to assess the effect of a hospital-wide programme to optimize albumin use in a tertiary referral university-affiliated hospital. METHODS This study was conducted in three 45-day phases, separated by two sequential interventions: guideline implementation and albumin order-sheet consideration. We evaluated albumin use and assessed its appropriateness in each phase at baseline, after guideline implementation and after order-sheet consideration. RESULTS We recorded 100, 93 and 71 albumin orders for 100, 84 and 66 patients during the first, second and third phases, respectively. The adjusted number of albumin orders (used albumin vials) was 94.9 (1481.7 vials), 80.8 (1037.6 vials) and 66 (1219 vials) in the first, second and third phases of the study, respectively. Albumin orders with appropriate indication increased significantly over the three phases of the study (OR=1.5, P=.008). The frequency of inappropriate orders reduced significantly from the first phase to the third phase (58%-27%, P=.007). WHAT IS NEW AND CONCLUSION The pattern and amount of albumin use changed following guideline implementation and order-sheet consideration, and inappropriate albumin use was reduced in our hospital. There was still room for improvement, particularly for indications that were not included in the guideline. Hence, a more comprehensive guideline, frequent audit, feedback and interactive educational approaches might be necessary to achieve results that are of a greater magnitude.
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Affiliation(s)
- B Laki
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - M Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - M Assarian
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - K Heidari
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - H Torkamandi
- Pharmaceutical Care Department, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M R Javadi
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - K Gholami
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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29
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Flannery AH, Pandya K, Laine ME, Almeter PJ, Flynn JD. Managing the Rising Costs and High Drug Expenditures in Critical Care Pharmacy Practice. Pharmacotherapy 2016; 37:54-64. [PMID: 27995636 DOI: 10.1002/phar.1862] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pharmaceutical costs for patients in the intensive care unit (ICU) constitute a large portion of hospital drug budgets. Unfortunately, prices for medications commonly used in the ICU are on the rise for a variety of reasons. In particular, the U.S. Food and Drug Administration's Unapproved Drugs Initiative, generic manufacturers cornering the marketplace, drug shortages, and regulatory device changes are major drivers of pharmaceutical price escalation affecting costs in the ICU. Furthermore, traditional high acquisition cost items still pose challenges to controlling costs. To offer strategies to mitigate the rising costs of pharmaceuticals in the ICU setting, we searched the PubMed/Medline and International Pharmaceutical Abstracts databases and other related sources to identify published cost-saving protocols concerning specific medications that are affected by rising prices or have traditional high acquisition costs. In the absence of specific protocols, we offer possible cost-saving initiatives based on published literature regarding specific agents or based on our own diverse set of experiences. Finally, we review suggested clinical and operational activities at an institutional level to address these rising drug costs in the ICU setting.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Komal Pandya
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Melanie E Laine
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Philip J Almeter
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Jeremy D Flynn
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
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