1. TABLE 1: CLINICAL USE OF ALBUMIN
Rationalizing Human Albumin Use in a Turkish Hospital: A Disinvestment Decision Using HTA
Rabia Kahveci1 , Yasar Karaaslan1, Elife Dilmac1, Meltem Nuzumlali Koc,1 Erdem Gurkas1, Aydin Alper Sahin1, Nurullah Zengin1 1Ankara Numune Training and Research Hospital, HTA Unit
Introduction
Results
Ankara Numune Training and Research Hospital (ANEAH) is a teaching hospital in Turkey, covering 38 clinical specialties. Its budget for 2012 is 100 million Euros. The hospital has been the first hospital in the country to adopt HTA, being its first application for disinvestment purposes. In 2011, the hospital pharmacy noticed that the use of human albumin (HA) rose from 1561 boxes in 2006, to 6165 in 2008, and to 8406 by 2010 (Figure 1). The rapid increase in the use has not been explained by any change in the type of services provided, neither by changes in the profile of patients. The chief of medical staff asked to investigate whether this raise match the current scientific knowledge about clinical indications of HA.
The indications for HA usage at the hospital is compared with the literature search; doctors’ HA usage tendencies are evaluated. Our review revealed considerable diffferences between indications in our hospital than the literature. A guideline has been prepared and distributed to the physicians for rational use of HA and doctors are asked to follow the guideline. After this stage, doctors’ HA usage is screened in 6 months and 12 months following guideline dissemination (Figure 2).
Changes in doctors’ HA usage habbits after the implementation of guideline are quite remarkable. HA consumption decreased by 48% in the first 6 months, which further declined by 70% within a year. Also a change in the indications for usage is observed. The main indication for HA use was formerly hypoalbuminemia whereas this is not a sole indication for HA use according to current scientific knowledge and is not recommended in the guideline. After only a few months of guideline, the use of this indication is almost diminished.
The effects of this change on HA usage costs at the hospital are also estimated. The expected savings with this intervention is over 500,000 TL (app 220,000 euros) in a year, with no expected loss of benefits for the patients.
Figure 1
What is Human Albumin?
Albumin is a medium weight colloid which accounts for about 50% of the overall content of plasma protein. It is responsible for about 80% of the intravascular oncotic pressure. It facilitates fluid retention in the intravascular space. Albumin has been used from the World War II. The first case is a series of seven very severely burned patients treated with intravenous administration of human albumin after they had been injured during the Pearl Harbor attack. The role of HA is, however, still controversial and its use may be based more on custom than on a scientific basis. Because of its limited availability and high cost, it is imperative that the use of HA is restricted to indications for which it is efficacious. The arguments over its pros and cons are long-standing. Some meta-analyses which have tried to clarify the place of HA have resulted in widely divergent conclusions. The indications for the use of HA according to our evidence based guideline is shown on Table 1.
TABLE 1: CLINICAL USE OF ALBUMIN
Sepsis
Burns
Trauma
Major surgery
Hemorragic shock
Therapeutic plasmapheresis
Ovarian hyperstımulatıon syndrome
Refractory ascites
Large volume paracentesis
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Nephrotic syndrome
Malnutrition, and enteropathies/malabsorption syndrome
Figure 2
Conclusions
Rational use of medicines is important both for patient safety and efficient use of resources. This is quite remarkable in settings such as hospitals where huge number of patients are admitted and extensive consumption of medicines occur. HTA is not only a tool for aiding investment decisions but could also be useful for disinvestment decisions.
The current study has been useful to show policy makers how HTA could be used for disinvestment decisions, how rationalizing medicine use has extensive impact on resources, importance of involvement of physicians in HTA processes and impact of guideline implementation in local settings.
Methods
Review of current use of HA in hospital by clinical services and indications at ANEAH. Cost analysis on HA consumption over time. Literature search and review on HA use. Development of an evidence-based guideline to overcome inappropriate use of HA. Guideline dissemination to users of HA. Impact analysis through clinical record review.