Mitigating the Overutilization and Financial Impact of Intravenous Magnesium Repletion

From the 2019 HVPAA National Conference

Dr. Nimish Shah (University of Texas Southwestern), Mr. Chris Mathew (Parkland Health & Hospital System), Dr. Timothy J. Brown (University of Texas Southwestern), Mr. Albert Karam (Parkland Center for Clinical Innovation), Dr. Deepak Agrawal (University of Texas Southwestern), Dr. Sandeep Das (University of Texas Southwestern)

Background

Serum magnesium levels ([Mg]) are often maintained at >2 mg/dl in hospital patients despite poor correlation between serum and total body Mg stores and lack of data supporting routine Mg repletion. Oral Mg oxide (MgO) is as effective as intravenous (IV) Mg sulfate (MgSO4) at repleting Mg stores but is significantly more expensive.

Objective

To determine and reduce the frequency and relative cost impact of IV versus oral Mg repletion at our institution.

Methods

We queried our EHR for all instances in which Mg was administered within 24 hours after a serum [Mg] measurement among adults at a large, tertiary-care county hospital from 10/2017 to 10/2018, excluding obstetric and perioperative uses. The data collected included serum [Mg], route of administration, and patient location. Using the average wholesale pricing for IV and oral Mg, we determined the potential cost savings of a change in route (medication costs only, not including administration costs). We then implemented an indication-specific magnesium order panel with interdepartmental input to replace individual IV Mg orders among Medicine services. This quality improvement study was deemed exempt from IRB review.

Results

Overall, there were 19,288 instances of Mg repletion, of which 82% were via IV route. After order panel deployment, overall weekly Mg orders did not change, but Medicine IV orders were reduced by 43%. The projected estimated annual cost savings is >$50,000 among Medicine services and >$120,000 overall.

Conclusion

Mg administration is common at our institution and the IV route predominates. Overall, the pattern of IV MgSO4 use at our institution suggests widespread overuse with a substantial financial impact. A simple EHR-based intervention was associated with a marked reduction in IV orders, without affecting overall Mg utilization. Further implementation studies of strategies to reduce IV use are warranted, and efforts to expand the EHR order panel hospital-wide are underway.

Clinical Implications

Unnecessary administration of medications by the IV route is often costlier and technically more cumbersome than the oral alternative, thus reducing overall value and patient comfort. Here, we confirm the higher systemic cost of IV Mg and demonstrate a simple intervention to reduce cost without impairing clinicians’ ability to supplement Mg, thus improving value while highlighting opportunities for improvement such as limiting serum Mg measurements.

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