Analysis of the Cost-Effectiveness of Inhaled Pulmonary Vasodilator Therapy in Adults

Abstract

Background:

In adults, inhaled epoprostenol (iEPO) is FDA-approved to treat pulmonary hypertension, but also commonly used in other off-label clinical situations like hypoxemia. This pharmaceutical agent improves oxygenation, inhibits platelet aggregation, reduces inflammation, and decreases pulmonary vascular resistance. Currently, there are gaps in the literature regarding initiation, weaning and discontinuation criteria for hospitals that use iEPO for hypoxemia. However, the use of iEPO for hypoxemia continues to persist and this use, despite the cost, often occurs in an unregulated manner. Scientific, relevant evidence is essential in clinical care and policy-creation. The purpose of this study was to describe iEPO use through retrospective charting review of cases for which iEPO was initiated; to determine treatment effectiveness; and to determine the utility of a protocol for initiation, weaning and discontinuation of iEPO.

Methods:

Following IRB approval, a retrospective chart review was conducted for all patients who received iEPO at our institution from 2015 through 2017. Primary data points recorded to assess oxygenation were the PaO₂/FIO₂ ratio, the oxygen index, the mean airway pressure (MAP) and arterial oxygen saturation. Ventilator settings were recorded in addition to nitric oxide use, prone positioning, and the patient outcome (mortality). Weaning strategies were described and creation of an evidence- based protocol (EBP) was modeled to reveal potential cost savings.

Results:

Retrospective review of 329 patients receiving iEPO for hypoxemia revealed inconsistencies in the following: starting dose of iEPO, method of weaning and time to discontinuance when not clinically effective. Secondary to charting inconsistencies, weaning strategies could not be articulated. Application of the protocol model for cases in which the medication was not effective revealed $487,334.15 of waste in the system, which is illustrated in the figure below.

Conclusions:

A clinical practice guideline is recommended to standardize use, weaning and discontinuation. The use of a clinical practice guideline may result in eliminating unnecessary patient charges as well as expenses to our institution. Future prospective studies are needed to determine the effectiveness of applying the clinical practice guideline to iEPO use, to evaluate the standardization of care and to deliver efficient care.