Impact of a sequential intervention on albumin utilization in critical care

Objectives: Literature generally finds no advantages in mortality risk for albumin over cheaper alternatives in many settings. Few studies have combined financial and nonfinancial strategies to reduce albumin overuse. We evaluated the effect of a sequential multifaceted intervention on decreasing albumin use in ICU and explore the effects of different strategies. Design: Prospective prepost cohort study. Setting: Eight ICUs at two hospitals in an academic healthcare system. Patients: Adult patients admitted to study ICUs from September 2011 to August 2014 (n = 22,004). Interventions: Over 2 years, providers in study ICUs participated in an intervention to reduce albumin use involving monthly feedback and explicit financial incentives in the first year and internal guidelines and order process changes in the second year. Measurements and Main Results: Outcomes measured were albumin orders per ICU admission, direct albumin costs, and mortality. Mean (sd) utilization decreased 37% from 2.7 orders (6.8) per admission during the baseline to 1.7 orders (4.6) during the intervention (p < 0.001). Regression analysis revealed that the intervention was independently associated with 0.9 fewer orders per admission, a 42% relative decrease. This adjusted effect consisted of an 18% reduction in the probability of using any albumin (p < 0.001) and a 29% reduction in the number of orders per admission among patients receiving any (p < 0.001). Secondary analysis revealed that probability reductions were concurrent with internal guidelines and order process modification while reductions in quantity occurred largely during the financial incentives and feedback period. Estimated cost savings totaled $2.5M during the 2-year intervention. There was no significant difference in ICU or hospital mortality between baseline and intervention. Conclusions: A sequential intervention achieved significant reductions in ICU albumin use and cost savings without changes in patient outcomes, supporting the combination of financial and nonfinancial strategies to align providers with evidence-based practices.