In the JournalsPerspective

ART stewardship optimizes HIV care, saves money

David Koren, PharmD, BCPS, AAHIVP
David Koren

ART stewardship teams helped identify and correct ART-related errors, resulting in improved care for patients with HIV, according to findings published in Open Forum Infectious Diseases.

“Persons living with HIV regularly experience medication-related errors during hospitalizations,” David Koren, PharmD, BCPS, AAHIVP, clinical pharmacist specialist in infectious diseases at Temple University Hospital, told Infectious Disease News. “Our study describes the effect of a directed antiretroviral stewardship program, which improved patient safety and provided a significant cost avoidance.”

The ART stewardship teams were composed of an HIV pharmacist specialist, infectious diseases physicians and “associated learners,” according to Koren and colleagues.

In a retrospective cohort study, the researchers assessed the electronic health records of adult hospitalized patients with active ART orders who were admitted to Temple University Hospital between July 1, 2017, and June 30, 2018. They reviewed the number of interventions made by the stewardship team, the number of admissions with ART-related medication errors, risk factors for the occurrence of ART-related medication errors, and cost savings.

“Temple is not the first to form such a team,” Koren said. “We are the first, however, to provide a cost savings correlation with a program such as this.”

The analysis included 567 admissions, with 336 total interventions by the stewardship team. According to the study, at least 43% of admissions had at least one intervention. Most patients were aged between 45 and 64 years, and many were treated by an internal medicine service, treated with a multitablet inpatient regimen, had an integrase inhibitor component of their ART regimen, and had a CD4 count of 200 cells/mm3 or greater.

Koren and colleagues found that a multitablet inpatient regimen (OR= 1.834; 95% CI, 1.16-2.899), admission to the ICU (OR = 2.803; 95% CI, 1.28-6.136), care provided by a surgery service (OR = 1.762; 95% CI, 1.082-2.868), an increased number of days to interdisciplinary review of medication (OR = 1.061; 95% CI, 1.008-1.117) and having a noninstitutional outpatient provider (OR = 1.375; 95% CI 0.972-1.946) were all risk factors for error.

The researchers estimated that the 1-year cost savings totaled $263,428.

“While this exact model may not be applicable to everyone, institutions can assess the volume of people living with HIV that they serve, as well as their own resources for infectious diseases/HIV experts to implement an approach that is right for them,” Koren said. – by Marley Ghizzone

Disclosures: Koren reports serving on medical advisory panels for Gilead Sciences and ViiV Healthcare, and reports receiving investigatory initiated research finding from Gilead. All other authors report no relevant financial disclosures.

David Koren, PharmD, BCPS, AAHIVP
David Koren

ART stewardship teams helped identify and correct ART-related errors, resulting in improved care for patients with HIV, according to findings published in Open Forum Infectious Diseases.

“Persons living with HIV regularly experience medication-related errors during hospitalizations,” David Koren, PharmD, BCPS, AAHIVP, clinical pharmacist specialist in infectious diseases at Temple University Hospital, told Infectious Disease News. “Our study describes the effect of a directed antiretroviral stewardship program, which improved patient safety and provided a significant cost avoidance.”

The ART stewardship teams were composed of an HIV pharmacist specialist, infectious diseases physicians and “associated learners,” according to Koren and colleagues.

In a retrospective cohort study, the researchers assessed the electronic health records of adult hospitalized patients with active ART orders who were admitted to Temple University Hospital between July 1, 2017, and June 30, 2018. They reviewed the number of interventions made by the stewardship team, the number of admissions with ART-related medication errors, risk factors for the occurrence of ART-related medication errors, and cost savings.

“Temple is not the first to form such a team,” Koren said. “We are the first, however, to provide a cost savings correlation with a program such as this.”

The analysis included 567 admissions, with 336 total interventions by the stewardship team. According to the study, at least 43% of admissions had at least one intervention. Most patients were aged between 45 and 64 years, and many were treated by an internal medicine service, treated with a multitablet inpatient regimen, had an integrase inhibitor component of their ART regimen, and had a CD4 count of 200 cells/mm3 or greater.

Koren and colleagues found that a multitablet inpatient regimen (OR= 1.834; 95% CI, 1.16-2.899), admission to the ICU (OR = 2.803; 95% CI, 1.28-6.136), care provided by a surgery service (OR = 1.762; 95% CI, 1.082-2.868), an increased number of days to interdisciplinary review of medication (OR = 1.061; 95% CI, 1.008-1.117) and having a noninstitutional outpatient provider (OR = 1.375; 95% CI 0.972-1.946) were all risk factors for error.

The researchers estimated that the 1-year cost savings totaled $263,428.

“While this exact model may not be applicable to everyone, institutions can assess the volume of people living with HIV that they serve, as well as their own resources for infectious diseases/HIV experts to implement an approach that is right for them,” Koren said. – by Marley Ghizzone

Disclosures: Koren reports serving on medical advisory panels for Gilead Sciences and ViiV Healthcare, and reports receiving investigatory initiated research finding from Gilead. All other authors report no relevant financial disclosures.

    Perspective
    Gitanjali Pai

    Gitanjali Pai

    The role of stewardship teams and their contribution to clinical care cannot be overemphasized. Despite recent advances in ART, the rate of inpatient ART errors is high. With HIV regimen compromises that can jeopardize the health of patients, there is certainly a need for inpatient ART stewardship. This study highlights the benefits of the invaluable interprofessional partnership with an ART stewardship team. Continuous review and documentation, as underscored by this study, does provide the added benefits of tracking errors, and thereby patient safety, in real time, as evidenced here. Despite the advent of newer ART with fewer predicted drug-drug interactions, or DDIs (eg, integrase inhibitor drugs) the potential for DDIs exists nevertheless, and DDIs must be monitored. With increased awareness of spiraling health care costs, estimated financial savings are undoubtedly an important consideration. As the first study to report the estimated cost savings associated with an ART stewardship program, although retrospective, it does shed light on the positive financial impact of ART stewardship on the health care system. Considering that ART-related errors can be multifactorial and complex, with several nonquantifiable long-term implications, multiple checkpoints would be essential and helpful to minimize errors or lapses and a dedicated interdisciplinary ART stewardship team would serve that purpose.

    • Gitanjali Pai, MD, AAHIVS
    • Infectious Disease News Editorial Board member
      Memorial Hospital
      Stilwell, Oklahoma

    Disclosures: Pai reports serving on the advisory boards of AbbVie and Gilead Sciences.