Terry Field, D.Sc. Meyers Primary Care Institute University of Massachusetts Medical School, Fallon Community Health Plan, Fallon Clinic

Development and implementation costs Immediate, direct costs and savings Potential additional savings

Long-term care setting CDSS to provide prescribers with patient- specific maximum dosing recommendations based on renal function Added to a commercial EHR with integrated CPOE (Meditech) Included 62 drugs; 94 alerts specific to the level of renal insufficiency

Internal physicians, pharmacists, informatics project manager, project coordinator, health services researcher weekly reports from each participant with hours by category External specialized programmer tracked through bills submitted

Reported hours combined with US national average hourly wages for the appropriate personnel categories Submitted bills from external programmer

CategoryHoursCost ($) % of total time Physicians41425, Pharmacist – MS1205,30713 Pharmacist – BS601,8146 Informatics Project Manager1224,98713 Project Coordinator801,3159 Researcher Programmer1108,81312 Total92448,668

ActivityHoursCost ($)% of total cost Determining contents48227,45556 Preparing blueprints for programmer511,8694 Programming1108,81318 Testing and implementing793,3227 Informatics project management1224,98710 Project coordination802,2205 Total92448,668

1)CPOE system does not require specialized programmer Hours: 924, Cost: $43,268 2)Database for renal dosing exists Hours: 657, Cost: $34,201 3)CDSS Product exists Hours: 475, Cost: $23,695

Ambulatory setting – large group practice Automated alert system to provide PCPs with: - notification of hospital and SNF discharges - new drugs added during hospital stay - recommendations related to dosing and monitoring - reminders to support staff to schedule follow- up visit Added to a commercial EHR with CPOE (EpicCare Ambulatory EMR)

CategoryHoursCost ($)% of total time Physicians61455,34047 Operations research analyst37012,56128 Research assistant2023,88516 Registered nurse581,8734 Computer software engineer401,6923 Database administrator Pharmacist73671 Total1,30876,314

ActivityHoursCost ($)% of total cost Determining content16914,97720 Designing and preparing HIT application33015,84720 Developing blueprints for programming32514,91720 Programming27317,40623 Testing/revising1648,95411 Project management Maintaining262,2313

Substantial time required from clinical personnel! - determining contents (or reviewing if purchased) - extensive time spent testing

Long-term care setting Within an RCT of the renal dosing CDSS described earlier Randomized by unit within a large long-term care facility Costs and savings related to drugs and laboratory tests

Drugs that triggered an alert as prescriber began the order vs. drugs actually ordered All drug orders for the day of an alert reviewed to identify potential substitutes Drug costs based on US wholesale price at the time Serum creatinine tests ordered within 24 hrs of alert of missing lab information – costs based on Medicare allowable payments at the time of the order

Within both intervention and control units, we compared costs for initial vs. final submitted drug orders Adjusted findings from the intervention units by findings in the control units Note: even in the control units, prescribers changed their minds during an order!

Estimated savings for drug orders: $2,160 Estimated additional costs for lab orders: $769 Total estimated savings: $1,391

Setting: large, multispecialty group practice providing care to >30,000 Medicare enrollees Case-control study nested in a cohort study that identified adverse drug events from 7/1/1999 to 6/30/2000 Control group – for each subject with an event, we randomly selected a control matched by having an encounter and dispensing in the month prior to the event

Outcome measure: costs of medical care from 6 weeks prior to the event through 6 weeks after In-patient stays, ED visits – national average of cost-to-charge ratios MD visits, dx tests, therapy, lab, ambulance use, home health, DME – Medicare fee schedules Pharmaceuticals – average wholesale cost on day dispensed

Average total costs for cases and controls calculated and plotted Estimated surge in costs calculated by subtracting pre-event costs from post-event costs for each individual MVA with cost surge as outcome and case status as exposure, controlling for confounders Analyzed for 1225 case/control pairs and 325 pairs for preventable ADEs

Component of costIncrease in costs after preventable ADE* (95% confidence interval) Total1983 (193, 3773) In-patient stays1222 (-320, 2763) ED visits111 (17, 205) Out-patient care571 (227, 915) Prescribed meds79 (24, 134) *Controlling for age, gender, Charlson comorbidity index, # scheduled meds, hospitalization in pre-period

1,000 enrollees age 65+ for 1 year 13.8 preventable ADEs $27,365 (CI $2,663, $52,067) in 2000 dollars All Medicare enrollees age 65+ in 2000 $887 million for preventable adverse drug events

Development costs are significant Development (or even implementation) requires extensive time from clinicians Immediate, direct cost savings may be minor Savings from reductions in adverse events are likely to be substantial Complete, detailed tracking of adverse events and their associated costs is a large and expensive task!