November 13, 2019 - CC

PIP Spotlight: Decreasing Pharmacy-Related Expenditures Without Impacting Patient Care

Jeffrey Cheng, MD completed this Practice Improvement Project while working as a resident. The goal of Dr. Cheng’s PIP was to lower inpatient pharmacy-related expenses through a formulary substitution without impacting patient care.

The PIP Spotlight is a periodic feature on News Center to highlight exemplary Practice Improvement Projects submitted by your fellow diplomates (or residents) for Maintenance of Certification (MOC) Part IV credit.

Diplomates can use the PIP Spotlight as a tool to model additional PIPs on what you read here, or as a way to connect with other diplomates doing similar work. Keep in mind–anyone working on the same project can claim credit by completing the PIP form (including residency program directors); you simply need to describe your unique role in the project.

Thanks to Dr. Cheng for his Practice Improvement Project submission, and congratulations on working ahead on your MOC requirements!

What is the problem you are trying to solve?

This is a financial quality improvement project with the goal of decreasing inpatient pharmacy-related expenditures through formulary changes without impacting care. Specifically, I wanted to replace the preferred liquid potassium supplementation from potassium chloride to potassium bicarbonate.

What data (objective measurements) do you have that supports this as a problem?

The current cost for potassium chloride ranges from $7.32-10.41 for 20/mEq, based on the supplier. The current cost for potassium bicarbonate is $0.40 per tablet of 20/mEq. Based on pharmacy purchase order data from 2017-2018, much more potassium chloride was being ordered from the suppliers compared with potassium bicarbonate, which means that more potassium chloride is being ordered for liquid potassium supplementation compared to potassium bicarbonate.

What is your opportunity statement? State the goal you hope to achieve.

The goal of this project is to decrease the average monthly pharmacy expenditure for inpatient oral potassium supplementation based on the monthly purchase order sent to suppliers (oral potassium supplementation includes KCl powder, KCl cups, and KHCO3).

What is the underlying cause of the performance/quality problem?

In the current reimbursement model for acute inpatient rehabilitation services, rehabilitation facilities are paid using a bundled care model as opposed to a true fee-for-service reimbursement model. Under such constrained financial conditions, rehabilitation facilities need to minimize expenses while delivering quality care. There are multiple contributors to excess expenditures, including pharmacy-related costs. The underlying issue is that potassium chloride is more expensive than potassium bicarbonate, but no one in our institution has analyzed the potential cost savings if potassium bicarbonate were used as liquid potassium supplementation instead of potassium bicarbonate. There are other contributors to this issue including a training bias to prescribe potassium chloride, and lack of physician awareness of the cost differential between potassium chloride and potassium bicarbonate.

What change(s) did you implement?

We created a general potassium supplementation order set under which "liquid potassium supplementation" is a subset with potassium bicarbonate as the preferred liquid potassium supplementation; it was anticipated that this would change ordering behaviors while still allowing the ordering provider to order potassium chloride when clinically indicated. We also created and implemented a protocol for inpatient pharmacists to review orders and contact the ordering provider to change potassium chloride to potassium bicarbonate when appropriate.

Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?

Yes. I averaged the monthly liquid potassium supplementation (KCl cups, KCl packets, and KHCO3 effervescent tablets) before and after the change. After the change, the average monthly liquid potassium cost decreased from $3,091 to $1,086. This resulted in a projected annual cost savings for liquid potassium supplementation of about $24,057 when comparing 2017-2018 and 2018-2019.

Additionally, outcomes were tracked to ensure that potassium bicarbonate was making appropriate serum potassium level changes and it was (on average, 40 meq --> 0.3 mEq/L rise in serum potassium). The change to serum bicarbonate did not result in a change in the number of adverse events. However, there were a couple cases of metabolic alkalosis usually in the setting of comorbid disease states (renal disease or emesis), baseline metabolic alkalosis, and multiple doses of potassium bicarbonate supplementation.

Will you continue with the changes you have implemented?

The changes that were made were retained. In addition to the initial changes to increase the amount of KHCO3 ordered for liquid potassium supplementation, new protocols were put into place for pharmacists to ensure the potassium bicarbonate was not being ordered for patients with serum bicarbonate levels of more than 26 for patients with other disease states that can predispose them to metabolic alkalosis. This financial QI project has led to the possibility of analyzing other medications to see if further changes could be made to make a bigger impact on cost savings for the institution.