Introduction: In 2010, the AHA/ASA’s Target Stroke best practice recommendations to reduce door to needle times (DTN) included early pre-mix of intravenous alteplase, which ultimately leads to unused vials. However, hospitals have largely recouped the cost of unused, premixed vials through returns to the drug manufacturer, although this practice is unlikely to continue. As a result, we evaluated an intervention to reduce the number of returned vials and the impact on clinical care at our certified primary stroke center (PSC).
Methods: A 6-month pre-intervention period (January 2015-June 2015) was compared to two 6-month post-intervention periods, July 2015-December 2015 and January 2016-May 2016. Acute ischemic stroke patients presenting at our PSC and considered for alteplase treatment were included. Inpatient strokes or those with diagnoses unrelated to stroke or uncertain treatment eligibility were excluded. Primary outcomes were as follows: 1. Percent of alteplase vials returned out of the total number mixed and the associated costs 2. Average DTN time 3. Pharmacy alteplase mix time to needle time. Average minutes (min) with associated p-values and 95% confidence intervals (95%CI) were reported. Price for replacement vials ranged from $6,400 to $8,400 per 100 mg vial.
Results: Data from 95 AIS patients were included. The percentage of alteplase returns for the evaluation period were as follows: 40.6% (13/32) for the pre-intervention, 11.4% (4/35) for the first post-intervention and 6.1% (2/33) for the second post-intervention period. Total cost savings was between $128,000 and $168,000 comparing pre and post-intervention periods. Among those treated, DTN times were not significantly different between pre-intervention (55.5 min, n=19), post-1 (59.7 min, n=27) and post-2 (49.9 min, n=30) (p=.13, 95%CI: 50.6,59.1). Similarly, the pharmacy alteplase mix times to needle times were also not significantly different (16.6 min vs 14.8 min vs 11.8 min) across the three time periods (p=.14, 95%CI:12.2,15.9).
Conclusion: The percentage of vials returned reduced by over 6-fold after the intervention resulting in considerable cost savings. PSCs can reduce overall waste of alteplase and decrease costs without negatively effecting clinical care.