Avoiding cost avoidance

We applaud Dr. Erstad’s commentary on justification of the value of critical care pharmacist services and share in the belief that every patient managed in an intensive care unit (ICU) should receive the care of a critical care pharmacist.¹

Yet, we want to caution both readers and future investigators against resting on the laurels of cost avoidance alone. First, cost avoidance is largely based on a paucity of data, reflecting poor-quality evaluations and expert opinion.² Previous reports using these values have received notable criticism for the risk of overstating a pharmacist’s value.^3,4 However, we note that, while estimated cost savings may be artificially higher when based on these low-quality data, even if the return on investment (ROI) ratio is a half or a quarter of the predicted ratio of 25:1 (noted in the most recent position statement for critical care pharmacists ⁵; ie, 12:1 or 6:1), this ROI is still extremely significant for the profession of pharmacy and the disciplines of both critical care and emergency medicine. However, pharmacists must view themselves in roles beyond holding the interprofessional team accountable to cost-avoidance goals and apply metrics evaluating ROI that are most appropriate to these roles.

Most significantly, evaluating the ROI of additional pharmacist services is a function of the value metric used. As such, to evaluate ROI based on cost avoidance alone may ultimately be self-defeating, as it fails to acknowledge the true impact of pharmacists on the quality of patient care delivered and additional resources quicky lose value. We illustrate this point in Figure 1. In an ICU with no pharmacist resources, adding a pharmacist will produce a large cost savings and a high ROI, even with high pharmacist-to-patient ratios that are likely not optimal for patient outcomes or employee wellness. The bulk of these cost savings may be associated with institution-focused, high-level initiatives (eg, albumin stewardship or formulary substitution) that can be achieved with limited resources. Adding further resources to this ICU may lead to only minimal or even no additional benefit with respect to cost avoidance, as reflected by a reduced ROI for each additional resource. Indeed, further addition of resources may actually lead to a negative ROI when based on this metric alone.

Figure 1.

Why metrics matter for critical care pharmacist-to-patient ratios. These 2 figures depict how metric achievement (top) and metric achievement as a function of cost or return on investment (bottom) change based on the number of full-time employees (FTE) and potential pharmacist-to-patient ratios. Ultimately, evaluation of pharmacist productivity (and associated return on investment) is based on the specific metric of interest. For example, with cost avoidance, this goal may be achieved with the addition of a single pharmacist, meaning that any further resources will actually reduce return on investment (blue lines). However, if metrics such as scholarly activities as outlined in the position statement are used, the return on investment may increase for each additional employee (orange lines).

We posit that, if the value of a clinical pharmacist were based on medication safety, patient-centered outcomes (eg, mortality and length of stay), or even optimal activities, as recently outlined, ROI would likely be optimized only at the point of much lower pharmacist-to-patient ratios or at a time when every ICU patient had a dedicated critical care pharmacist. Recognizing the global contributions and impact of a pharmacist in the clinical setting and evaluating resources based on clinically oriented metrics is an important step toward the acceptance of pharmacists as providers in the patient care arena.

Disclosures: Dr. Newsome has received research funding through the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers UL1TR002378 and KL2TR002381. The authors have declared no potential conflicts of interest.