An educational initiative to reduce costs associated with volatile agent use

Abstract Background: Inhalational anesthetic agents represent a large portion of hospital pharmacy budgets due to their use in enormous quantities. In June of 2008, the scholarly project of an anesthesiology resident discovered a dramatic difference in the price of our volatile agents in MAC-hours, identifying an opportunity to reduce spending on volatile agents. By educating staff on the specific benefits and cost of each agent in MAC-hours, we have driven change in our drug selection algorithm. Time series analysis shows that an educational initiative in 2008 has had a sustained decrease in volatile agent expenditure for 10 years. Methods: To implement a new drug selection algorithm across our organization, key stakeholders were identified to include the operating room pharmacy and the nurse anesthetists that performed most of the anesthetics. Champions in the main inpatient operating room helped to implement default isoflurane use in that suite and it was sustained for the subsequent decade. Detailed volatile anesthetic purchasing data and data from our electronic medical record were analyzed. Following an initial educational intervention emphasizing the pharmacokinetic and economic benefits of isoflurane, a new volatile agent selection algorithm was implemented at Wake Forest in the hope that it would become the default agent chosen when there was not a compelling reason to use another drug. Our pharmacy was asked to maintain a new monthly par stock of volatile anesthetic agents and to adjust their subsequent monthly purchasing of volatile agents so as to replace only what was used the prior month. This newly implemented algorithm has persisted for a decade in the inpatient operating suite through the orientation of onboarding providers and the ongoing education of trainees. We obtained the monthly pricing and acquisition data from Wake Forest Baptist Health for the 12 year period ending in 2019, and we measured the total amount spent on volatile agents each year. We queried our electronic medical record for the number of cases using volatile agents, the average dose of volatile anesthetic given each year, and the average fresh gas flow rate. We then used an interrupted time series analysis of monthly cost per unit data using autoregressive integrated moving average (ARIMA) modeling, with the monthly cost per unit being the amount spent per bottle of anesthetic per month. Results: Following the implementation of the new drug selection algorithm, there was a statistically significant decrease in volatile agent expenditure (t = -2.754, p = 0.007) that has been sustained (t = 0.867, p = 0.387) for 10 years. Isoflurane has been the predominant agent purchased each year since implementation. One operating room suite implemented this drug selection algorithm and drove cost reduction that was sustained for the subsequent decade. Conclusions: We have kept all inhalational agents and their vaporizers on the anesthesia machine and available for selection, but encourage the default use of isoflurane because of its lower price and favorable pharmacokinetic properties. Through continuing education of trainees and onboarding of providers, isoflurane has remained the predominant volatile anesthetic chosen in the main inpatient operating suite at Wake Forest for the past decade. All three agents have continued to be used in great quantity as anesthetic case volumes increased over the past decade. However, our expenditure for volatile anesthetics has still been decreased by hundreds of thousands of dollars each year compared to the pre-intervention cost because of the successful implementation of this educational initiative in a single operating suite.