When IV acetaminophen costs skyrocketed, one health system did some new math

Chandler Regional Medical Center is a 339-bed not-for-profit community hospital in Chandler, Ariz. The center is part of the Dignity Health System, the fifth-largest hospital system in the United States. Like all healthcare providers, Dignity Health must be vigilant in the face of escalating drug costs.

See also: The pharmacist's role in preventing acetamophen overdoses

Through the roof

In May 2014, Mallinckrodt Pharmaceuticals purchased Cadence Pharmaceuticals, the manufacturer of injectable acetaminophen (Ofirmev). At the time of purchase, Mallinckrodt increased the cost of injectable acetaminophen from $14.60 to $35.05 for each 1-g vial. This was a 140% increase over and above the 37% price increase implemented by Cadence during the three years before the company’s acquisition.

See also: The ups and downs of generic drugs

At this point, Dignity Health resolved to reduce the system’s use of injectable acetaminophen. Members of the system’s Clinical Pharmacy Group spent a month researching the available literature and discussing their findings. They then developed a draft Intravenous (IV) Acetaminophen Guideline, which permitted use of IV acetaminophen outside the perioperative area when the patient was unable to tolerate oral (PO) medications. For patients who were candidates for IV acetaminophen, duration was limited to 24 hours.

At Chandler Regional, use of IV acetaminophen was restricted to its orthopedic surgeon, who was using post-operative (post-op) acetaminophen 1 g IV Q 8h for 2 doses in all of his patients. Because of the lack of available literature comparing IV vs. PO acetaminophen in orthopedic surgery, Chandler Regional’s clinical pharmacy coordinator and orthopedic surgeon decided to conduct an internal retrospective study comparing post-op acetaminophen 1 g IV Q 8h for 2 doses and acetaminophen 1 gram PO Q 8h for 2 doses, given to post-op hip- and knee-replacement patients. 

The study

With the vote on the health system’s IV Acetaminophen Guideline looming, time constraints required Chandler Regional to limit its study to 62 patients. Each treatment group included 31 patients. Patient population characteristics were similar in regard to sex, age, weight, and type of surgery.

Except for the two post-op acetaminophen 1-g doses, all patients received the same post-op multimodal pain therapy. Four patients in the IV acetaminophen group and seven patients in the PO acetaminophen group were on opioid medication(s) at home.

Outcome data included total opioid use on post-op Day 0 and Day 1; use of antiemetics on post-op Day 0 and Day 1; and hospital length of stay.

See also: Acetaminophen awareness: A community survey

Findings

The outcome data did not show any major differences between the two treatment groups in regard to post-op opioid use on Day 0 or day 1:

• On post-op Day 0, the IV acetaminophen group used 41.6 mg of PO morphine equivalents, and the PO acetaminophen group used 27.6 mg of PO morphine equivalents. Therefore on post-op Day 0, there was a total of 14 mg more PO morphine equivalents used in the IV acetaminophen group.

• On post-op Day 1, the IV acetaminophen group used 24.7 mg and the PO acetaminophen group used 24.6 mg of PO morphine equivalents. Similarly, there was no difference in as-needed (PRN) antiemetic use on post-op Day 0 or Day 1.

• The IV acetaminophen group used 6 doses of PRN antiemetics on post-op Day 0 and 6 doses on post-op Day 1. The PO acetaminophen group used 8 doses of PRN antiemetics on post-op Day 0 and 4 doses on post-op Day 1.

• The average length of stay was similar between the two groups (2.68 days for the IV acetaminophen group and 2.97 for the PO acetaminophen group). 

Implementation and cost savings

On the basis of Chandler Regional’s internal study of IV vs. PO acetaminophen, the hospital endorsed Dignity Health’s IV Acetaminophen Guidelines in September 2014. In addition, Chandler Regional’s orthopedic surgeon stopped using scheduled IV acetaminophen post-operatively and now uses PO acetaminophen. 

Chandler Regional also saw a decrease in IV acetaminophen expenditures. Before implementation of the IV Acetaminophen Guideline, Chandler Regional spent $23,308.17 per month on IV acetaminophen. In December 2014, three months after the Guideline was implemented, Chandler spent roughly $10,500 less, with a total IV acetaminophen cost of $12,938.65.

Clinical Pharmacy Coordinator Julie Princeandorthopedic surgeon Danton Dungypractice at Chandler Regional Medical Center in Chandler, Ariz. Contact Julie Prince atJulie.Prince@dignityhealth.org.