A cost effectiveness analysis of a quality improvement intervention to increase preferential balanced fluid prescribing

Background: The higher cost of balanced fluids has historically contributed to preferential normal saline (NS) use. Recent clinical trials demonstrated that balanced fluids reduced the incidence of major adverse kidney events among hospitalized patients and also reduced mortality among critically ill patients. This study sought to conduct an economic evaluation of a recently published quality improvement (QI) intervention to increase preferential balanced fluid prescribing, which significantly increased the relative proportion of balanced fluid orders.

Methods: Using clinical trial data and real-world data from our prior QI intervention in conjunction with local and regional cost data, we constructed a decision tree to examine the economic cost and clinical consequences of using NS, lactated ringers (LR), and plasma-lyte for 30,000 hypothetical adult patients and 1,290 hypothetical critically ill adult patients with sepsis admitted to our institution over one year. Clinical outcomes (hospitalization to day 30) included development of acute kidney injury (AKI), new requirement for renal replacement therapy (RRT), and in-hospital mortality. The primary economic outcome was the difference in cost between the pre- and post-QI intervention periods. Sensitivity analyses and breakeven analyses were performed. Evaluation was conducted from South Carolina hospitals' perspective.

Results: For the overall cohort, simulation predicted that 53 AKIs, 2 instances of RRT, and 62 deaths were avoided in the post-intervention year with a net cost savings of $704,507. For the critically ill patients with sepsis, simulation predicted that 32 AKIs, 4 instances of RRT, and 12 deaths were avoided with a net cost savings of $474,676. Sensitivity analyses using outcome data from additional clinical trials also estimated annual cost savings ($77,677-$414,872).

Conclusions: The QI intervention was predicted to improve patient outcomes while yielding significant cost-savings. The marginally increased cost of balanced fluids should not discourage implementation of interventions aimed at increasing evidence-supported balanced fluid prescribing.