2026 Southeastern Residency Conference

Purpose:
    Hospital-acquired anemia (HAA) is a common complication of hospitalization and is associated with increased length of stay, healthcare costs, readmissions, and mortality. Although anticoagulation therapy carries a known bleeding risk, its role as an independent contributor to HAA has not been well defined. This study evaluated compared the incidence of HAA in non-surgical hospitalized patients receiving prophylactic versus therapeutic anticoagulation.
Methods:
    This retrospective cohort study included adults (≥18 years) hospitalized for more than 4 days who received prophylactic or therapeutic anticoagulation for over 75% of their admission. Prophylactic regimens included subcutaneous heparin, prophylactic-dose enoxaparin, or fondaparinux 2.5 mg daily. Therapeutic anticoagulation included direct oral anticoagulants, intravenous heparin, therapeutic-dose enoxaparin, argatroban, or fondaparinux ≥ 5 mg daily. Patients were required to have hemoglobin measured on admission and within 72 hours of discharge. Exclusion criteria included anemia on admission, surgical procedures (excluding minor/low-risk procedures), therapies affecting hemoglobin, or documented physiologic bleeding.
Results:
    Hospital-acquired anemia occurred in 44.8% of patients receiving prophylactic anticoagulation and 51.3% receiving therapeutic anticoagulation, with no significant difference between groups (p = 0.28). No differences were observed in anemia severity, absolute hemoglobin change (p = 0.93), or rate of hemoglobin decline (p = 0.74).
Conclusion:
    Hospital-acquired anemia was common in non-surgical hospitalized patients, with no significant differences between prophylactic and therapeutic anticoagulation. Anticoagulation intensity alone may not be a primary contributor to HAA.

TITLE: Incidence of Mechanical Ventilation in the Emergency Department among Patients with Acute Pulmonary Edema Utilizing High versus Low Dose Intravenous Nitroglycerin

AUTHORS: Saralyn Hardin, Kira Council, Erica Merritt, Megan Cavagnini

BACKGROUND: Heart failure affects approximately 2% of adults in the United States, with an estimated 33% at risk of developing the condition. It is classified into progressive stages, with Stage C characterized by symptomatic disease and Stage D representing advanced heart failure. Patients with Stage D heart failure frequently experience debilitating symptoms that significantly impact daily life and often result in recurrent hospitalizations. According to the American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines, nitroglycerin may be considered for the management of pulmonary edema in acute heart failure presentations, provided hypotension is not present. Nitroglycerin is a targeted vasodilator that primarily reduces preload; at higher doses, it also induces arterial vasodilation, thereby decreasing afterload. While typically initiated at low infusion rates, higher rates (≥100 mcg/min) have demonstrated improved clinical outcomes in the treatment of pulmonary edema.

METHODS: This retrospective, observational chart review evaluated the incidence of mechanical ventilation in patients in the emergency department at St. Joseph’s or Candler Hospitals diagnosed with acute pulmonary edema based on the nitroglycerin dose in the first hour of treatment.  The health system’s software and a computer-generated list using MedMined services was used to identify patients with acute pulmonary edema then filtered based on the inclusion and exclusion criteria between January l, 2023, and January 1, 2024.
Patients were identified, and data was gathered to include demographic information, nitroglycerin infusion rate within the first hour, blood pressure, baseline serum creatinine and admission location. The primary objective was to determine the rate of mechanical ventilation in patients who received high dose nitroglycerin in comparison to those who received low dose nitroglycerin. The secondary endpoints of the study were the average nitroglycerin dose within the first hour of initiation, admitted level of care, percent of patients that develop acute kidney injury or hypotension after infusion initiation, average length of time in minutes the infusion was active, and all-cause mortality.

RESULTS: Three patients were screened for eligibility with 36 meeting inclusion criteria. Ten (27%) received high dose nitroglycerin (rate ≥100mcg/min) and 26 (72%) received low dose nitroglycerin (rate <100mcg/min). The mean number of patients requiring mechanical intubation was found to be 0.2 in the high dose nitroglycerin compared to 0.04 in the low dose group. Of the thirty-six patients three required mechanical ventilation and one of the three had a prior medical history revealing asthma and chronic obstructive pulmonary disease. Overall, there was found to be no statically significant correlations between the nitroglycerin dosing group and adverse events including admittance into the intensive care unit, incidence of hypotension, incidence of acute kidney injury, and all-cause mortality.

CONCLUSION: The overall nitroglycerin dosage administered to patients during the first hour following a pulmonary edema diagnosis was not comparable to the incidence of mechanical intubation in prior studies. Considering the study’s limitations of small sample size, further research with larger, multicenter data should explore potential relationship between nitroglycerin dosing within the first hour of diagnosis to adverse events.

Title: Evaluating the implementation of prolonged beta-lactam infusions for sepsis patients in the ICU
Authors: Nathaniel Park, Jeremy Frens, Alex Chappell, and Dustin Zeigler
Background/Purpose:
Beta-lactams are generally the preferred and most frequently prescribed antibiotics to treat patients with sepsis due to their broad spectrum of activity and favorable safety profile. Their efficacy is dependent on time above minimum inhibitory concentration (MIC) with requirements depending on beta-lactam class. Therefore, patients are at risk of treatment failure if beta-lactam concentrations at the site(s) of infection fall below the MIC for extended periods of time. Recently, data from the BLING-III trial and subsequent meta-analyses have suggested that there may be benefits in terms of clinical cure and reduced 90-day mortality with prolonged beta-lactam infusions in comparison with conventional, intermittent infusions. As a result, Cone Health adopted prolonged or continuous infusion protocols for piperacillin/tazobactam, penicillin G, and nafcillin. More recently, additional prolonged infusion protocols were implemented for cefepime, ceftazidime, and meropenem in critically ill patients with sepsis or septic shock. The aim of this study was to evaluate the efficacy and safety associated with the implementation of a prolonged infusion regimen protocol for cefepime, ceftazidime, and meropenem in ICU patients with sepsis or septic shock.
Methodology:
This Institutional Review Board (IRB) reviewed, determined exempt, retrospective, multicenter, single-health system, pre-post study was conducted from October 2024 to December 2025. Patients were included if they were > 18 years old; ICU admission for sepsis or septic shock; had documented site of infection or strong suspicion for bacterial infection; initiated on meropenem, cefepime, or ceftazidime < 24 hours from sepsis or septic shock diagnosis; and > 1 sign of organ dysfunction [mean arterial pressure (MAP) < 60 mm Hg for > 1 hour, vasopressor required > 4 hours, respiratory support required for > 1 hour, or serum creatinine > 2.49 mg/dL]. Exclusion criteria included renal replacement requirement at the time of antibiotic initiation, received antibiotics < 48 hours, and antibiotics not initiated within 24 hours of sepsis diagnosis. Baseline demographic data, safety data, and data relevant to the primary and secondary endpoints were collected among eligible patients. The primary endpoint was ICU length-of-stay (LOS) defined as days on ICU unit. Secondary endpoints were clinical cure (defined as completion of antibiotics within 14 days without resumption within 48 hours of cessation), vasopressor-free days, and 30-day all-cause mortality. Continuous data was analyzed with Student’s t-test or Mann-Whitney U test, and categorical data was analyzed with chi-square test or Fisher’s exact test. Two-sided alpha was set at 0.05.
Results:
In total, 200 patients were screened for inclusion (100 in pre- and 100 in post-intervention cohort). Ultimately, 38 patients were analyzed – 18 in the pre-intervention cohort, and 20 in the post-intervention cohort. Less than half of the patients were female (n=17, 44.7%) with an average age of 71 years old. Most patients were started on cefepime (n=29, 76.3%), with pulmonary and urinary sources accounting for most of the suspected sepsis sources (n=28, 73.7%). Of the 20 patients in the post-intervention cohort, 14 patients met criteria for prolonged beta-lactam infusion. Among patients meeting criteria (n=14), 1 patient (7.1%) received prolonged beta-lactam infusion. For the primary endpoint, the post-intervention group had a shorter median ICU LOS (2.7 vs 5.0 days, p=0.285). For secondary endpoints, the post-intervention group had less vasopressor-free days (0.7 vs 1.1 days, p=0.055), reduced 30-day mortality (15.0% vs 33.3%), and increased clinical cure (90.0% vs 77.8%). One occurrence of a new C. difficile infection occurred, which was in the pre-intervention cohort, and beta-lactams were appropriately renally adjusted in the 27 patients meeting criteria for renal dosing.
Conclusions:
Although numeric differences were observed in favor of the prolonged beta-lactam infusion protocol cohort with decreased ICU LOS, increased vasopressor-free days, 30-day mortality, and clinical cure, there were no statistical differences among any of the primary or secondary endpoints. Additionally, the observed low implementation rate of prolonged beta-lactam infusion among eligible patients further complicates interpretation. Most likely, the cohort identification methods did not have the sensitivity to identify more patients administered prolonged beta-lactam infusions. The results of this study should not dissuade use of the prolonged beta-lactam infusion protocol.

Title: Comparison of Nicardipine and Labetalol for Peri-Thrombolysis Blood Pressure Management in Acute Ischemic Stroke
Authors: Olivia Klassa, Braiden Sorgenfrei, Michael Wagner, Alex Ewing, Lauren McAbee 
Background:  
Acute ischemic stroke requires rapid thrombolytic therapy to restore cerebral blood flow and optimize outcomes; however, safe administration depends on effective blood pressure control. Current AHA/ASA guidelines recommend reducing blood pressure to less than 185/110 mmHg prior to tenecteplase and maintaining less than 180/105 mmHg for 24 hours after administration. Elevated blood pressure may delay thrombolytic administration and increase hemorrhagic risk. Labetalol and nicardipine are commonly used first-line agents, though limited evidence supports a preferred option. This study aims to compare labetalol and nicardipine for their impact on door-to-needle time and 24-hour blood pressure control in patients receiving tenecteplase for acute ischemic stroke. 
Methods:  
A retrospective chart review was conducted at an 864-bed academic medical center in Greenville, South Carolina, between January 1, 2021, and October 31, 2025. Adults with acute ischemic stroke who received tenecteplase and required pre-thrombolysis blood pressure management with nicardipine or labetalol were included. Eligible patients were identified using a report from the Get With The Guidelines–Stroke database. Patients with hemorrhagic stroke, pregnancy, or receipt of alternative antihypertensives were excluded. The primary outcome was door-to-needle time. Secondary outcomes included time to blood pressure control, 24-hour blood pressure variability, antihypertensive utilization, and clinical outcomes including bleeding, mortality, and functional and neurologic status. 
Results:  
A total of 100 patients met inclusion criteria and were included in the final analysis. Of these, 38 received labetalol alone, 25 received nicardipine alone, 31 required escalation from labetalol to nicardipine, and 6 required escalation from nicardipine to labetalol prior to TNK administration. Baseline characteristics were similar between groups, though the nicardipine group had a higher prevalence of hypertension and greater outpatient antihypertensive use. Median door-to-needle time was similar between groups (28 vs. 33 minutes, p=0.09), and a similar proportion of patients achieved a door-to-needle time less than or equal to 30 minutes. However, a greater proportion of patients receiving labetalol achieved door-to-needle times less than or equal to 15 minutes (15.8% vs. 0%, p=0.02). Door-to-CT times were also similar across groups. Time to blood pressure control differed significantly between strategies, with labetalol achieving faster control compared to nicardipine (4 minutes vs. 8 minutes, p=0.001). Patients requiring escalation between agents experienced longer times to blood pressure control. Blood pressure parameters during the first 24 hours, as well as safety and functional outcomes, were similar across treatment strategies. 
Conclusions:  
The findings of this study demonstrate that antihypertensive strategy prior to TNK administration did not significantly impact door-to-needle time in patients presenting with acute ischemic stroke. While labetalol achieved faster time to blood pressure control compared with nicardipine, this difference did not translate into meaningful differences in treatment timing or clinical outcomes. Safety and functional outcomes were also similar between treatment strategies. These findings should be interpreted in the context of the retrospective single-center design and small sample sizes.

Linezolid as Empiric Therapy for Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia: A Retrospective Cohort Analysis of Clinical Outcomes  
Katherine Albus, Kellee Geren, Samantha Walker, Brandon Hawkins 
The University of Tennessee Medical Center, Knoxville, TN 
 
Background/Purpose: Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most difficult-to-treat Staphylococcus species worldwide, with mortality exceeding 20%. Vancomycin (VAN) or daptomycin (DAP) are considered first-line empiric therapies for MRSA bacteremia.  Small subgroup analyses have suggested improved survival and faster bacteremia clearance with linezolid (LZD) versus glycopeptides, yet its role is largely unclear. This study aimed to compare the effectiveness of LZD versus VAN or DAP in patients with MRSA bacteremia.   
 
Methodology: This single-center, retrospective, observational cohort study included hospitalized between December 2017 and June 2024. The primary outcome was a composite of 60-day all-cause mortality and bacteremia persisting greater than 7 days. Secondary outcomes included the individual components of the composite outcome, duration of antimicrobial therapy, duration of bacteremia, and ICU admission. Eligible patients were 18 years of age or older, had at least one MRSA-positive blood culture, and received empiric LZD, VAN, or DAP for at least 48 hours from culture collection. VAN and DAP were assessed as composite groups. Exclusion criteria included death or transition to hospice within 48 hours of culture collection, failure to receive a study antibiotic within 3 hours of culture, receipt of a comparator antimicrobial for more than 24 hours, or lack of susceptibility to the empiric agent. 
 
Results: There was no difference in patients receiving LZD or VAN/DAP in the primary composite outcome (0% LZD vs. 43.8% VAN/DAP; P = 0.074) or the individual components of 60-day all-cause mortality (0%  LZD vs. 19.8%  VAN/DAP; P = 0.580) and persistent bacteremia greater than 7 days (0% LZD vs. 32.6% VAN/DAP; P = 0.319). The median duration of antimicrobial therapy was numerically shorter in the LZD group compared with the VAN/DAP group (19.5 days vs. 43 days, respectively), though this was not significant (P = 0.143). ICU admission rates during treatment were comparable between groups (20% LZD vs. 38% VAN/DAP; P = 0.646). The duration of bacteremia was significantly shorter among patients treated with LZD compared to VAN/DAP, with median durations of 2.4 days and 5.5 days, respectively (P = 0.036). 
 
Conclusions: In a small sample, empiric LZD for MRSA bacteremia demonstrated comparable rates of 60-day mortality and persistent bacteremia compared with VAN or DAP. LZD demonstrated a significantly shorter duration of bacteremia than VAN/DAP, although these findings may be due to LZD use in less complicated infections. These results, when considered alongside existing clinical and pharmacologic evidence, support further investigation of LZD as a potential first-line option for MRSA bacteremia. Larger, prospective studies are needed to better define the role of LZD in uncomplicated, Gram positive infections with Gram negative coverage where appropriate.  

Link: https://docs.google.com/document/d/e/2PACX-1vQzRhZffUvSQUgtz-e88XOkxVPWlCJON2KHAtHhLXttKCpq05YARaPn9673tC8gAzP64x3Ss3WU3wYN/pub

Angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) provide cardiovascular and renal protections across hypertension, chronic kidney disease, and heart failure populations, yet are often held during episodes of acute kidney injury (AKI). Optimal timing of post-AKI reinitiation remains uncertain. We aimed to compare outcomes among patients whose ACEi or ARB therapy was restarted at different times.   
 
We conducted a single center, retrospective cohort study of adult inpatients with AKI whose ACEi, ARB, or ARNI therapy was held ≥24 hours during hospitalization. Patients were categorized into 3 groups depending on whether therapy was restarted during hospitalization, restarted upon discharge, or not continued at discharge. The primary endpoint was complete renal recovery at 90 days. Secondary endpoints were AKI readmission rates within 90 days of discharge, cardiovascular events and all-cause mortality at 12 months, and time to treatment reinitiation in group 3. 
 
Among 148 patients (Group 1, n=41; Group 2, n=52; Group 3, n=55), there was no significant difference across groups in renal recovery at 90 days (73.2%, 59.6%, 67.3%, respectively; p=0.13). AKI readmission rates within 90 days (9.8%, 19.2%, 9.1%, respectively; p=0.25), cardiovascular events within 12 months (17.1%, 7.7%, 18.2%, respectively; p=0.22), and all-cause mortality within 12 months (12.2%, 5.8%, 7.3%, respectively; p=0.53) were similar across groups. Median (SD) time to reinitiation in group 3 was 60 ±94 days (p=0.049). 
 
Early reinitiation of ACEi or ARB after AKI did not worsen renal recovery at 90 days or increase adverse events. These findings support timely reinitiation with appropriate monitoring.  

Background: 
Methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs are commonly used to safely discontinue empiric MRSA coverage in patients due to their high negative predictive value (NPV) of greater than 98% for MRSA infections. While MRSA nasal swabs have a high NPV, they are not well studied to guide de-escalation in mechanically ventilated patients. Limited guidance exists on de-escalation in mechanically ventilated patients prior to respiratory culture results leading to continuation of empiric antibiotics for an extended duration. This study aims to evaluate the predictive value and stewardship of MRSA nasal swabs in mechanically ventilated trauma patients with ventilator associated pneumonia (VAP). 

Methods:  
This is a single-center, retrospective prevalence study of adults admitted to the Surgical Critical Care (SCC) service with a traumatic injury who were mechanically ventilated for greater than or equal to 48 hours from January 2020 through January 2025. Patients who received a MRSA nasal swab, bronchoalveolar lavage (BAL), and empiric antibiotics for MRSA pneumonia were included in the study. The primary outcome is to establish positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of MRSA nasal swab results. 

Results: MRSA nasal swabs demonstrated a PPV of 58.3% (95% CI 30.4%-86.2%) while the NPV was 97.1% (95% CI 91.4%-100%), a sensitivity of 87.5% (95% CI 64.6%-100%), and a specificity of 86.8% (95% CI 76.1%-97.6%). The median turnaround time for MRSA nasal swab results was 26.4 hours (IQR 25.5,27.6), compared to 48.7 hours (IQR 44.6,64.3) for BAL culture results. 

Conclusions: This study demonstrates that MRSA nasal swabs possess a high NPV in mechanically ventilated trauma patients with VAP and the rapid turnaround time for MRSA nasal swab results compared to BAL cultures provides a clinical advantage for timely antibiotic de-escalation. 

Background: Intravenous (IV) iron is an effective therapy for iron deficiency anemia, and growing evidence supports outpatient administration when clinically appropriate. Despite this, hospitalized patients frequently receive IV iron without a standardized process to ensure therapy completion after discharge. To address this gap, the adult iron replacement order set was updated to better facilitate ambulatory infusion referrals and incorporate a pharmacist consult. The consult prompts inpatient clinical pharmacists to review indication for IV iron with the ordering provider and determine whether remaining doses can be safely administered in the outpatient setting or if additional inpatient doses are medically necessary. The purpose of this study was to evaluate the impact of these order set changes on outpatient IV iron referral rates. 

Methods: This multi-center, IRB-reviewed determined exempt, retrospective cohort study evaluated adult patients receiving IV iron across four Cone Health hospitals and affiliated outpatient infusion centers. Patients with IV iron orders placed through the inpatient infusion order set during the study period were included. The primary outcome was the proportion of hospitalized patients receiving IV iron who were referred for outpatient infusion. Chi-square test was utilized to compare pre-intervention (September 17, 2024–May 12, 2025) and post-intervention (May 13, 2025–October 31, 2025) cohorts for the primary outcome. Secondary outcomes included the proportion of referred patients who received at least one outpatient IV iron dose, the proportion who completed their planned outpatient IV iron treatment course, median time from discharge to first outpatient IV iron administration, median time from discharge to first outreach for infusion scheduling, and reasons for incomplete outpatient IV iron treatment among referred patients. Descriptive statistics were used to summarize baseline characteristics. 

Results: Data on 201 patients were collected from both the pre- and postimplementation phases. During the pre-intervention period, 1,430 hospitalized patients received inpatient IV iron, with 36 patients (2.5%) referred for outpatient infusion. In the post-intervention period, 1,131 hospitalized patients received inpatient IV iron, and 168 patients (14.6%) were referred for outpatient infusion (p < 0.001).  Among referred patients, 31 of 36 patients (86.1%) in the pre-intervention group and 99 of 165 patients (60.0%) in the post-intervention group received at least one outpatient IV iron dose (p = 0.0029). Overall, 24 of 36 patients (66.7%) in the pre-intervention group and 88 of 165 patients (53.3%) in the post-intervention group completed their planned IV iron treatment course (p = 0.1445). Median time from hospital discharge to first outreach for infusion scheduling was 4 days (range 0–81) in the pre-intervention group and 3 days (range 0–30) in the post-intervention group. Median time from discharge to first outpatient IV iron administration was 13 days (range 5–91) in the pre-intervention group and 11 days (range 8–18) in the post-intervention group. The most frequently identified barriers to treatment completion were no-shows, inability to contact patients, rehospitalization, patient-directed delays, and documentation gaps. 

Conclusions: Implementation of an updated IV iron order set incorporating pharmacist review significantly increased referrals for outpatient IV iron therapy. Standardizing referral workflows at hospital discharge may improve continuity of care, support timely outpatient iron repletion, and optimize utilization of inpatient and ambulatory infusion resources.

Introduction:    
Some of the most prescribed medications in the elderly population have potent anticholinergic properties, which are associated with potentially harmful side effects, such as an increased risk of falls. In addition, many elderly patients are on potentially inappropriate medications as defined by the Beers criteria, many of which can also increase fall risk. Pharmacists can play a pivotal role in preventing inpatient falls by proactively identifying patients taking potentially inappropriate medications and making recommendations related to de-prescribing or medication optimization. The objective of this study is to investigate if a causal relationship exists between inpatient falls and medication usage. 
Methods:  
This is a retrospective case-controlled study of adult patients aged 65 years or older admitted to The University of Tennessee Medical Center from January 2023 to May 2025. Patients were separated into two groups: the fall group, which included patients aged 65 years or older who had experienced an inpatient fall (as identified by ICD-10 codes for inpatient falls), and the control group, which included patients aged 65 years or older who had not experienced an inpatient fall. Patients were excluded if they were under 65 years old. The Anticholinergic Burden Score and the Beers Criteria scoring systems were utilized to assess the total number of potentially inappropriate medications the patients were taking at admission, during their hospital stay, and at discharge. The primary outcome is the median score on each scoring system at each time point: admission, during their hospital stay, and on discharge. Secondary outcomes are length of stay and discharge location. 
Results: 
A total of 310 participants met the inclusion criteria. Baseline characteristics were similar between groups except for a higher prevalence of atrial fibrillation in the no-fall group (P = 0.004). Both measures of potentially inappropriate medication exposure were significantly higher in patients who experienced a fall. Median Anticholinergic Burden scores were 4 vs 2 (P < 0.0001), and median Beers Criteria scores were 7 vs 5 (P < 0.0001) in the fall and no-fall groups, respectively. Despite no difference in admissions scores, the change in both metrics from admission to maximum inpatient values were significantly greater in the fall group (P < 0.0001). Patients who fell had a longer median length of stay (8 vs 4 days, P < 0.0001) and were more frequently discharged to skilled nursing facilities (P < 0.0001). A post-hoc analysis was conducted regarding past medical history for atrial fibrillation and Parkinson's disease, as they were significant or marginally non-significant, respectively. Each 1-point increase in Anticholinergic Burden Score increased fall risk by 26.9%, and each 1-point increase in Beers Criteria Score increased fall risk by 14.3% among patients with atrial fibrillation or Parkinson's disease. 
Conclusion: 
Patients who experienced an inpatient fall had significantly higher maximum Anticholinergic Burden and Beers Criteria scores than those who did not fall. Falls were also associated with longer hospital stays and a greater likelihood of discharge to a skilled nursing facility. Medication risk scores increased from admission through the time of the fall, suggesting an opportunity to improve inpatient medication optimization to prevent falls. Future research should evaluate high-risk medication combinations and dose-related effects within the Anticholinergic Burden and Beers Criteria to better guide prescribing for high-risk hospitalized patients. 

Title: Outpatient Medical (OPM) Drug Formulary Expansion to Optimize Margin
Authors: William Siders, David Collette
Background:
Drug formularies for the Centers of Medicare & Medicaid Services and commercial insurers are updated regularly, which can create reimbursement challenges related to misalignment between prescribed therapies and payer-specific formulary preferences. Administering non-preferred agents can result in claim denials and increased administrative burden for providers and pharmacy staff. At Huntsville Hospital Outpatient Medical Services, variability in insurance coverage across commercial and government payers highlighted the need for a standardized approach to formulary management. The purpose of this pharmacoeconomics project was to expand and standardize the outpatient medical drug formulary to align with current insurance preferences and maximize reimbursement.
Methodology:
A comprehensive review of our current formulary workhorse agents along with formulary requirements and coverage criteria across major commercial and government insurers was conducted. Based on this review, the Outpatient Medical Services drug formulary was updated to reflect payer-preferred agents by insurance type. Standardized, provider-facing communications were developed, including formal educational letters distributed to providers outlining formulary changes and payer-specific drug preferences. Educational efforts emphasized appropriate product selection at the time of prescribing and appropriate documentation to ensure alignment with each patient’s insurance coverage. Additionally, education was also provided to administrative staff to reduce the number of denial claims through changes in the prior authorization process. The project team also worked in conjunction with the Finance and Information Technology teams at Huntsville Hospital to ensure appropriate billing codes were being used for each product. Pharmacy services were designated as a centralized resource to support therapeutic interchange, prior authorization confirmation, and transition planning during implementation.
Results:
In 2025, a total of 499 denial claims were identified, representing a potential loss of $402,832. The most common reasons for denial included submission or billing errors (n=157), lack of medical necessity (n=103), and duplication of payments (n=32). In 2026, only one denial claim had occurred as of March 1, 2026. Formulary optimization identified certain brands of ustekinumab, infliximab, and tocilizumab as the largest negative margin products. Transitioning to payer-preferred agents and biosimilars (Yesintek/Wezlana, Avsola/Inflectra, and Tofidence) resulted in a projected margin improvement of approximately $350,000 for 2026. The most profitable products included IVIG, bevacizumab, and rituximab. Overall, the total projected margin increase for outpatient medical services in 2026 is estimated at 7-10%.

Conclusion:
Implementation of an insurance-aligned outpatient formulary was associated with improved projected reimbursement margins and a marked reduction in claim denials. Alignment with payer-preferred agents and improved documentation contributed to decreased denial rates and an increase in overall margin. This pharmacist-supported, multidisciplinary approach may enhance financial stability and operational efficiency in outpatient infusion practices.