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Wahidi MM, Haywood H, Bass GD, Nathanson I, Chowdhury A, Sangvai DG. Value-Based Care for Chest Physicians. Chest 2023; 163:1193-1200. [PMID: 36627080 DOI: 10.1016/j.chest.2022.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/08/2023] Open
Abstract
Value-based care aims to improve the health outcomes of patients, eliminate waste and unwarranted clinical variation, and reduce the total cost of care. Professional medical societies have put forward guidelines to raise awareness on unproven practice patterns (Choosing Wisely Campaign), and payers have sought to replace the traditional fee-for-service payment models with value-based contracts that share financial gains or losses based on achieving high-quality outcomes and lowering the cost of care. Regardless of whether their practices are engaged in value-based arrangements, chest physicians should seek understanding of these principles, participate in designing and implementing practical and impactful high-value initiatives in their practices, and have a national voice on the path forward.
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Affiliation(s)
| | | | - Geoffrey D Bass
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Care Bundles plus Detailed Nursing on Mortality and Nursing Satisfaction of Patients with Septic Shock in ICU. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:1177961. [PMID: 35783516 PMCID: PMC9246582 DOI: 10.1155/2022/1177961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/25/2022] [Accepted: 06/10/2022] [Indexed: 11/29/2022]
Abstract
Objective To evaluate the effect of care bundles combined with detailed nursing on the mortality and nursing satisfaction of patients with septic shock in the intensive care unit (ICU). Methods Ninety patients with septic shock in the ICU admitted to our hospital from April 2019 to April 2020 were recruited and assigned to an experimental group and a control group via the random table method, with 45 cases in each group. The control group adopted conventional nursing, and the experimental group received care bundles combined with detailed nursing. The nursing effect, satisfaction, and mortality of the two groups were compared. The “Glasgow Coma Scale” (GCS) was used to evaluate the coma of the patients, the “Coma Recovery Scale” (CRS-R) was used to assess the state of consciousness of the patients, and the “Hospital Anxiety and Depression” (HAD) scale was used to evaluate the patient's emotional status before and after the intervention. Results The experimental group showed a significantly higher nursing efficiency and better nursing satisfaction than the control group (P < 0.05). Lower mortality was found in the experimental group in contrast to the control group (P < 0.05). The experimental group had higher GCS scores and CRS-R scores and lower HAD scores than the control group (P < 0.05). Conclusion Care bundles plus detailed nursing for patients with septic shock in the ICU improve the nursing effect and nursing satisfaction, reduce the mortality rate, and mitigate the clinical symptoms of patients, which shows great potential in clinical application and promotion.
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Sacha GL, Kiser TH, Wright GC, Vandivier RW, Moss M, Burnham EL, Ho PM, Reynolds PM, Bauer SR. Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock. Crit Care Med 2022; 50:644-654. [PMID: 34605778 DOI: 10.1097/ccm.0000000000005305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Vasopressin is suggested as an adjunct to norepinephrine in patients with septic shock. However, after vasopressin was rebranded in November 2014, its cost exponentially increased. Utilization patterns of vasopressin after its rebranding are unclear. The objective of this study was to determine if there is an association between the rebranding of vasopressin in November 2014 and its utilization in vasopressor-dependent patients with severe sepsis or septic shock. DESIGN Retrospective, multicenter, database study between January 2010 and March 2017. SETTING Premier Healthcare Database hospitals. PATIENTS Adult patients admitted to an ICU with severe sepsis or septic shock, who received at least one vasoactive agent for two or more calendar days were included. INTERVENTIONS The proportion of patients who received vasopressin and vasopressin cost was assessed before and after rebranding, and evaluated with segmented regression. MEASUREMENTS AND MAIN RESULTS Among 294,733 patients (mean age, 66 ± 15 yr), 27.8% received vasopressin, and ICU mortality was 26.5%. The proportion of patients receiving vasopressin was higher after rebranding (31.2% postrebranding vs 25.8% prerebranding). Before vasopressin rebranding, the quarterly proportion of patients who received vasopressin had an increasing slope (prerebranding slope 0.41% [95% CI, 0.35-0.46%]), with no difference in slope detected after vasopressin rebranding (postrebranding slope, 0.47% [95% CI, 0.29-0.64%]). After vasopressin rebranding, mean vasopressin cost per patient was higher ($527 ± 1,130 vs $77 ± 160), and the quarterly slope of vasopressin cost was higher (change in slope $77.18 [95% CI, $75.73-78.61]). Total vasopressin billed cost postrebranding continually increased by ~$294,276 per quarter from less than $500,000 in Q4 2014 to over $3,000,000 in Q1 2017. CONCLUSIONS After vasopressin rebranding, utilization continued to increase quarterly despite a significant increase in vasopressin cost. Vasopressin appeared to have price inelastic demand in septic shock.
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Affiliation(s)
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
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Adie SK, Abdul-Aziz AA, Ketcham SW, Moles VM. Considerations for Inotrope and Vasopressor Use in Critically Ill Patients With Pulmonary Arterial Hypertension. J Cardiovasc Pharmacol 2022; 79:e11-e17. [PMID: 34654789 DOI: 10.1097/fjc.0000000000001155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pulmonary arterial hypertension (PAH) is a rare and progressive cardiopulmonary disease, characterized by pulmonary vasculopathy. The disease can lead to increase pulmonary arterial pressures and eventual right ventricle failure due to elevated afterload. The prevalence of PAH in patients admitted to the intensive care unit (ICU) is unknown, and pulmonary hypertension (PH) in the ICU is more commonly the result of left heart disease or hypoxic lung injury (PH due to left heart disease and PH due to lung diseases and/or hypoxia, respectively), as opposed to PAH. Management of patients with PAH in the ICU is complex as it requires a careful balance to maintain perfusion while optimizing right-sided heart function. A comprehensive understanding of the underlying physiology and underlying hemodynamics is crucial for the management of this population. In this review, we summarized the evidence for use of vasopressors and inotropes in the management of PH and extrapolated the data to patients with PAH. We strongly believe that the understanding of the hemodynamic consequences of inotropes and vasopressors, especially from data in the PH population, can lead to better management of this complex patient population.
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Affiliation(s)
- Sarah K Adie
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI
| | - Ahmad A Abdul-Aziz
- Division of Critical Care, Department of Internal Medicine, Stanford University, Palo Alto, CA; and
| | - Scott W Ketcham
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Victor M Moles
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Huang H, Wu C, Shen Q, Xu H, Fang Y, Mao W. The effect of early vasopressin use on patients with septic shock: A systematic review and meta-analysis. Am J Emerg Med 2021; 48:203-208. [PMID: 33975132 DOI: 10.1016/j.ajem.2021.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 05/02/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The effect of early vasopressin initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early start of vasopressin support within 6 h after the diagnosis on clinical outcomes in septic shock patients. METHODS We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of February 2021. We included studies involving adult patients (> 16 years)with septic shock. All authors reported our primary outcome of short-term mortality and in the experimental group patients in the studies receiving vasopressin infusion within 6 h after diagnosis of septic shock and in the control group patients in the studies receiving no vasopressin infusion or vasopressin infusion 6 h after diagnosis of septic shock, clearly comparing with clinically relevant secondary outcomes(use of renal replacement therapy(RRT),new onset arrhythmias, ICU length of stay and length of hospitalization). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). RESULTS Five studies including 788 patients were included. The primary outcome of this meta-analysis showed that short-term mortality between the two groups was no difference (odds ratio [OR] = 1.09; 95% CI, 0.8 to 1.48; P = 0.6; χ2 = 0.83; I2 = 0%). Secondary outcomes demonstrated that the use of RRT was less in the experimental group than that of the control group (OR = 0.63; 95% CI, 0.44 to 0.88; P = 0.007; χ2 = 3.15; I2 = 36%).The new onset arrhythmias between the two groups was no statistically significant difference (OR = 0.59; 95% CI, 0.31 to 1.1; P = 0.10; χ2 = 4.7; I2 = 36%). There was no statistically significant difference in the ICU length of stay(mean difference = 0.16; 95% CI, - 0.91 to 1.22; P = 0.77; χ2 = 6.08; I2 = 34%) and length of hospitalization (mean difference = -2.41; 95% CI, -6.61 to 1.78; P = 0.26; χ2 = 8.57; I2 = 53%) between the two groups. CONCLUSIONS Early initiation of vasopressin in patients within 6 h of septic shock onset was not associated with decreased short-term mortality, new onset arrhythmias, shorter ICU length of stay and length of hospitalization, but can reduce the use of RRT. Further large-scale RCTs are still needed to evaluate the benefit of starting vasopressin in the early phase of septic shock.
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Affiliation(s)
- Haijun Huang
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China
| | - Chenxia Wu
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China
| | - Qinkang Shen
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China
| | - Hua Xu
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China
| | - Yixin Fang
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China
| | - Wei Mao
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310018, Hangzhou, China.
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Kelly CE, Miller C, Darko W, Cwikla G, Mogle B, Featherly J, Marcinak R, Probst LA, Seabury R. A single-center cost analysis assessing a change in vasopressin formulation. Am J Health Syst Pharm 2021; 78:1238-1243. [PMID: 33821885 DOI: 10.1093/ajhp/zxab153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Cost savings achieved at an academic medical center by reformulating the institution's standard vasopressin infusions to reduce waste are described. SUMMARY After a retrospective review of vasopressin utilization over a 4-month period revealed that only approximately 40% of dispensed vasopressin units were actually administered to patients, pharmacy leaders determined that the institution's standard vasopressin concentration for continuous infusions (100 units in 100 mL of sodium chloride 0.9% injection) was resulting in substantial waste, as many infusion preparations were not needed within the 18- to 24-hour expiration window. A concentration of 20 units/100 mL was adopted as the new standard formulation for vasopressin continuous infusions, with use of alternative concentrations allowed on a restricted basis. A pre-post study to assess the impact of the formulation change indicated a 38.7% decrease in vasopressin utilization (from 21,900 to 8,480 units) relative to utilization in a retrospective sample of patients who received vasopressin infusions prior to the formulation change. This reduced utilization equated to a cost decrease of $55,656.20 (as calculated on the basis of 2017 cost estimates) or $77,214.23 (as calculated on the basis of 2019 cost estimates) for the time period collected. It was estimated that the new formulations could yield annual cost savings ranging from $222,625 to $308,857. CONCLUSION To our knowledge, this is the first description of cost savings following a change in formulation of vasopressin for continuous infusions. Other institutions could consider employing a similar approach in addition to the previously reported cost-saving interventions, such as lower vasopressin starting doses and vasopressin restriction policies.
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Affiliation(s)
- Courtney E Kelly
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Christopher Miller
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - William Darko
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Greg Cwikla
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Bryan Mogle
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Julianna Featherly
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | | | - Luke A Probst
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Robert Seabury
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY.,Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
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Abrupt Discontinuation Versus Down-Titration of Vasopressin in Patients Recovering from Septic Shock. Shock 2020; 55:210-214. [PMID: 32842024 DOI: 10.1097/shk.0000000000001609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare patient outcomes based on management of arginine vasopressin (AVP) during the recovery phase of septic shock (abrupt vs. tapering discontinuation). PATIENTS AND METHODS Multicenter, retrospective cohort study of patients receiving AVP with concomitant norepinephrine for septic shock. Primary outcome measure was time to intensive care unit (ICU) discharge (from decision to titrate or stop AVP). Secondary outcomes included ICU and hospital mortality, and incidence of hypotension. RESULTS A total of 958 (73%) abrupt discontinuation and 360 (27%) down-titration patients were included. Patient characteristics and septic shock treatment courses were similar between groups. Median time to ICU discharge was similar between abrupt discontinuation (7.9 days, 95% CI 7.2-8.7 days) and tapered patients (7.3 days, 95% CI 6.3-9.3 days, P = 0.60). After controlling for baseline discrepancies, down-titration was not an independent predictor of time to ICU discharge (HR = 0.99, 95% CI: 0.85-1.15, P = 0.91). There was no difference in ICU mortality (21.8% vs. 18.0%, P = 0.13) or hospital mortality (28.9% vs. 31.1%, P = 0.44). Although incidence of hypotension was similar (39.7% vs. 41.7%, P = 0.53), patients in the down-titration group more frequently required an escalation of AVP dose (5.7% vs. 11.1%, P < 0.001). Median AVP duration was shorter in the abrupt discontinuation group (1.4 days [IQR: 0.6-2.6 days] vs. 1.8 days [IQR: 1.1-3.2 days], P < 0.001). CONCLUSIONS A difference in time to ICU discharge was not detected between abrupt AVP discontinuation and down-titration in patients recovering from septic shock. In patients recovering from septic shock, abrupt discontinuation of AVP appears to be safe and may lead to shortened AVP duration.
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