Sugammadex: Use Criteria Optimization and Outcomes Data Evaluation

Introduction

Sugammadex sales reached $1.5 billion globally in 2021, placing it in the top 5 of medication spend for acute care. This project focuses on the assessment of value and outcomes of sugammadex in comparison with neostigmine/glycopyrrolate for the reversal of neuromuscular blockade.

The primary endpoint of this project was to develop evidence-based use criteria. The secondary endpoint was to realize a 90% reduction in the utilization of sugammadex across the system while prioritizing no impact to patient outcomes. The results of newly added use criteria demonstrated an 86% reduction in the utilization of sugammadex with no appreciable impact on measured outcomes.

Background

The purpose of this project was to determine the appropriate use for sugammadex, both from a value and outcomes perspective. Providing an in-depth analysis detailing sugammadex utilization and any benefits related to outcomes compared to traditional therapies would create a narrative by which to justify its premium cost.

The approach for this project was to extensively evaluate the literature to identify key measures that sugammadex impacted, create criteria to prioritize use around those measures, then track the related outcomes for a year to be incorporated into a dashboard for monthly review. Leaders from each of the key stakeholder teams were actively involved in the literature analysis, data point collection determination, and evaluation of collected monthly data.

Ongoing analysis of utilization trends, outcomes tracking, and provider feedback were provided to leadership for ongoing discussion. The evolution of medication evaluation is important—thinking beyond medication cost to a focus on value and outcomes associated with formulary decisions. This work has created an emphasis on more detailed pharmacoeconomic projections for the formulary management process.

Intervention Detail

A thorough literature evaluation and summary was completed to design an appropriate set of use criteria for sugammadex within the health system. Extensive conversations with key stakeholders were held at multiple points along the project timeline to further outline key points to consider for the use criteria development and finalization.

Based on the agreed upon criteria, the estimated goal reduction in utilization for the 12 months following implementation of the updated use criteria was set at 90%. The same team developed a set of strategic data points to collect from the electronic health record.

These data points would be collected for the pre-implementation period defined as January 2017 through August 2020, and the post implementation period from Sept 2020 to present. This would allow an appropriate analysis of those identified outcomes and make any adjustments signaled by either the data collected or provider feedback. A Power BI dashboard was created to help with the interpretation of these data and continued monitoring.

Outcomes and Impact

The primary endpoint of development of evidence-based use criteria was implemented in September 2020. The secondary endpoint of the project was nearly achieved, with actual reduction in utilization, based on new use criteria, of 86%.

Importantly, the measured outcomes showed no clinically significant differences. The data set contains approximately 155,000 surgeries, including all specialties having procedures that required reversal of neuromuscular blockade.

Specific datapoints included comparing sugammadex versus neostigmine/glycopyrrolate for average PACU time (93 min vs 91 min), average post-operative nausea/vomiting medication doses (0.13 vs 0.14), average anesthesia time (143 min vs 142 min), length of stay (2.4 vs 2.9), 30-day readmissions (5.9% vs 4.8%), emergency revisit rates (7.7% vs 7.4%), observation revisit rates (1.7% vs 1.5%), and urinary retention (1.4% vs 1.5%). The American Society of Anesthesia score was included as a layer in several measures.

Across all specialties, there has been no clinically significant differences in outcome measures identified. The overall reduction in utilization for the 12-month post-implementation period was 86%.

The financial impact was approximately $3.1 million in savings. This project detailed an evidence-based approach to develop clinically appropriate use criteria to optimize sugammadex utilization for the reversal of neuromuscular blockade. Finally, the project enhanced the value of medication use for the patient and health system.

About the Authors

Jerry Rebo, PharmD, BCPS, BCCCP, DPLA, Director, Pharmacy Value and Outcomes, Novant Health.

Andrea Reed, PharmD, MBA, BCPS, DPLA, Vice President, Pharmacy Services, Novant Health Pharmacy.