Incidence of Hypotension Associated With Two Different Vasopressin Discontinuation Strategies in the Recovery Phase of Septic Shock.

Introduction: Safe and effective vasopressor withdrawal strategies during the recovery phase of septic shock lack consensus and are not addressed in clinical practice guidelines. The purpose of this study was to compare the incidence of clinically relevant hypotension associated with different vasopressin (AVP) discontinuation strategies. Methods: This was a single-center, retrospective, cohort study, conducted at a university medical center over a three-year period. Adult patients ≥18 years with septic shock were included in the study. Patients were stratified into two groups; patients incrementally weaned from AVP and patients in which AVP was abruptly discontinued. The primary endpoint was to compare the incidence of clinically relevant hypotension between study groups up to 24 hours following discontinuation. Secondary analyses included the incidence of any hypotensive event up to 24 hours after AVP cessation, intensive care unit and hospital length of stay, and in-hospital mortality. Results: A total of 74 patients (n = 46 AVP wean and n = 28 AVP no-wean) met inclusion criteria and were included in the study. The primary outcome was not statistically different between groups. Clinically relevant hypotension occurred in 24 patients (52.3%) and 16 patients (57.1%) in the AVP wean and AVP no-wean groups, respectively (P = .68). There were no significant differences in any secondary clinical outcome between the two study groups. Conclusion: No differences were found in the incidence of clinically relevant hypotension, length of stay, or mortality between AVP weaning and no-weaning discontinuation strategies. These findings suggest incremental weaning and abrupt withdrawal of AVP are both acceptable discontinuation strategies.

Pharmacists Providing Palliative Care Services: Demonstrating a Positive Return on Investment.

Objective: To establish a return on investment (ROI) for a pharmacist position on a hospital-based palliative care (PC) team. Background: Utilizing a pharmacist to provide PC services is often overlooked as a solution to physician shortages. Integration of a pharmacist into PC teams yields a favorable ROI. Methods: A 16-month retrospective review comparing PC patients at two hospitals with consultative PC teams. The PC teams at the two facilities had identical full-time equivalent team members, except for a PC pharmacist at Facility 1. The PC pharmacist's ROI was calculated based on cost savings created by utilizing the PC pharmacist as a physician extender and costs attributable to preventable adverse drug events (pADEs) identified by the PC pharmacist. Results: An annual ROI of 1.2 to 2.9 million dollars was calculated, $125,760 from physician time saved and $1.1-2.8 million dollars from pADEs. A statistically significant difference in rates of pADEs was realized between the PC pharmacist and non-PC pharmacists at Facility 1 as well as between pharmacists at Facility 1 (PC pharmacist and non-PC pharmacists) and pharmacists at Facility 2 (non-PC pharmacists). Conclusion: A PC pharmacist's unique qualifications and perspective contribute to the value of care provided to PC patients. A favorable ROI that exceeds a pharmacist's annual salary was demonstrated in this analysis.

Expanding Palliative Medicine across Care Settings: One Health System Experience.

BACKGROUND: The success of our hospital-based Palliative Care program stimulated requests to duplicate the program across the health system continuum of care. OBJECTIVE: To develop a model of care focused on a high-need, high-cost population that could be implemented across all care settings, including hospitals and patients' homes. METHODS: To fiscally support program expansion from hospital to home, we conducted a retrospective cost analysis for home-based Palliative Care (HBPC)-enrolled patients with continuous claims months before program enrollment through date of death. The HBPC enrollees were evaluated against a cohort group of CMS (Centers for Medicare & Medicaid Service) and Medicare Advantage patients who did not participate in the HBPC program (n = 3135). Twenty-one months of claims leading up to the date of death were evaluated for both populations. The analysis was designed to test whether Palliative Care patients demonstrated less overall claims expense and service utilization in the same periods as patients without Palliative Care. Claim months were grouped into three-month clusters for evaluation and statistical testing of per member per month utilization and cost. RESULTS: Overall, HBPC patients demonstrated significantly less service utilization and cost in the months leading up to death. Cost differences were primarily driven by clear cost divergence in the last three months of life [$9,843 (PC) vs. $27,530 (C)]. Our program grew from a hospital-based program to include the establishment of a home-based program. CONCLUSION: Palliative Care programs can successfully expand outside hospital walls to serve a high need/high-cost patient population.