Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
IMPACT OF THE USE OF ALBUMIN FOR COMPLICATIONS OF CIRRHOSIS ON THE GLOBAL ALBUMIN CONSUMPTION AND PHARMACEUTICAL COSTS IN AN ACADEMIC HOSPITAL
F. Mirici-Cappa1, P. Caraceni1*, E. Gelonesi1, V. Bevilacqua1, B. Benazzi1, M. Domenicali1, F. Trevisani1, C. Puggioli2, M. Bernardi1
1Department of Clinical Medicine, Alma Mater Studiorum University of Bologna, 2U.O. Farmacia Azienda Ospedaliera, Policlinico S.Orsola-Malpighi, Bologna, Italy. *firstname.lastname@example.org
Background/aim: Human albumin prescription in clinical practice is often inappropriate, as many indications are still debated. In the field of Hepatology, albumin use is currently supported in specific settings by controlled clinical trials and guidelines of international scientific Societies. However, even in these indications, albumin administration is not wide-spread due to its high cost and the presence of potential cheaper alternatives. We thus aimed to assess the impact of in-hospital recommendations regulating albumin prescription in a referral institution for liver diseases.
Methods: In 2003, a multidisciplinary expert panel at Sant'Orsola-Malpighi University Hospital (Bologna, Italy) listed acute and chronic conditions for which albumin is indicated as first or second-line treatment or is not indicated at all by using a literature-based consensus method. In the field of liver diseases, indications included prevention of post-paracentesis circulatory dysfunction and renal failure induced by spontaneous bacterial peritonitis, hepatorenal syndrome, and refractory ascites. The latter indication, although still debated, is accepted by the Italian health care system. We analyzed the albumin prescription and related costs during the 3 years before and the 6 years after guidelines implementation.
Results: Prior guidelines implementation (2000-2002), the annual albumin consumption and costs (expressed as either absolute amount and percent of the total expenditure for pharmaceutics or hemoderivates) increased steadily about 25%. Since 2003, albumin consumption and its related costs declined approximately 20% remaining stable for the following 6 years. After guidelines implementation, complications of cirrhosis, being paracentesis and refractory ascites the most frequent, have become the predominant indications for albumin prescription (40% of patients), followed by major surgery including liver transplantation (25%), shock (22%), enteric diseases (7%), and plasmapheresis (3%). In contrast, prior guidelines implementation, malnutrition and hypoalbuminemia per se represented major indications for albumin prescription, mainly in surgical departments. Finally, the adherence to the protocol was close to 90% of the prescriptions.
Conclusions: Albumin use according the current international guidelines in Hepatology does not increase total albumin consumption and costs in a tertiary referral hospital, provided that albumin prescription is strictly regulated by practical recommendations aimed at avoiding its futile use in settings without scientific evidence of efficacy.