iNO Stewardship Utilizing Evidence-Based Medicine to Reduce Ineffective Use and Improve Expenditure

Abstract

Background: In 2017 UC Davis Health contract with Mallinckrodt was insufficient to meet our growing demand for inhaled nitric oxide (iNO). A mid-contract review was performed and renegotiated in September of 2017. Efforts began in earnest to evaluate stewardship of iNO to reduce ineffective use while improving expenditure of this medical gas. Trending data allowed for an in-depth usage review to guide stewardship. Widespread and largely unregulated use in the adult population was noted upon evaluation, indicating potential ineffective use. Daily reporting also allowed for identification of opportunities to leverage for negotiation of future contract terms. With a Children’s Hospital Nitric Oxide Stewardship Team in place, UC Davis Health embarked on an effort to utilize evidence-based medicine to reduce ineffective use and improve expenditure of iNO.

Methods: Stewardship of iNO in all demographics (adult, pediatric and neonatal) was moderated by Pharmacy and Therapeutics Committee, which received monthly reports on iNO use during initial phase. In this forum, a Children’s Hospital Nitric Oxide Stewardship Team comprised of Pediatric Pharmacy, Pediatric Cardiology, Neonatology, and Pediatric Critical Care was developed. A highly involved Chief Medical Officer held accountable adult ICU medical directors. Policy changes to reflect the involvement of the Children’s Hospital Nitric Oxide Stewardship Team were made, and additional policy edits outlined on-label/off-label indications, responsiveness, weaning strategies, and the need for continuation of iNO order to be written every 24 hours. Initiation of iNO was updated to require attending physician approval. An RT directed weaning approach in the NICU was adopted and added to policy.

Results: In 2017 UC Davis Health used 27,432 hours of iNO, and before renegotiating at the mid-contract review, was on pace to spend approximately $2,974,890 for the year. At the mid-contract review, a more favorable contract structure was adopted, which resulted in an actual spend of $2,307,362 – an approximate savings of over $660,000. After the first year of development and implementation of stewardship, UC Davis Health saw a decrease in utilization of iNO: 19,544 hours in 2018, and 15,776 hours in 2019.

Conclusions: iNO Stewardship utilizing evidence-based medicine reduced ineffective use and thus, cost. Trending data assists in identifying opportunities for accountability and education and allows for a better negotiating position when approaching contract renegotiation.