Impact of clinical pharmacist on cost of drug therapy in the ICU

Abstract

Objective

To determine whether the presence of Clinical Pharmacist affects the cost of drug therapy for patients admitted to the Intensive Care Unit (ICU) at Al-Hussein hospital at Royal Medical Services in Amman, Jordan.

Method

This study compares the consumed quantities of drugs over two periods of time. Each period was ten months long. In the second period there was a Clinical Pharmacist. The decrease in consumption rate of drugs is considered to be an indicator of the success of Clinical Pharmacist in the ICU, as any decrease in consumption rate reflects the correct application of Clinical Pharmacy practices. The cost of this decrease in consumption rate represents the total reduction of drug therapy cost.

Results

The total reduction of drug therapy cost after applying Clinical Pharmacy practices in the ICU over a period of ten months was 149946.80 JD (211574.90 USD), which represents an average saving of 35.8% when compared to the first period in this study.

Conclusion

The results of this study showed a significant reduction in the consumed quantities of drugs and therefore a reduction in cost of drug therapy. Such findings highlight the importance of the presence of Clinical Pharmacist in all Jordanian hospitals wards and units.

1. Introduction

As the preparation and manufacturing of drugs moved from pharmacists to the pharmaceutical manufacturing industry, and dispensing practices became functions that could be well done by new technology machines or by pharmacy technicians, the pharmacists role of counting and pouring has changed (Holdford and Brown, 2010). The dramatic increase in the volume of medications and therapy options increased the complexity of information in areas such as pharmaceutical formulation, drug related problems, rational drug use, dosage forms, pharmacodynamics, adverse effects, drug interactions, patient adherence to treatment, and pharmacoeconomics. To all these changes the pharmacists have responded in a positive way. In addition the physicians’ expertise may not be in these extended subjects as it is in patient diagnosis and disease treatment. Nurses also face difficulties as they do not have extra time and enough theoretical and practical background to comply with these developments (Parthasarathi et al., 2004).

Clinical pharmacy has been defined by the American College of Clinical Pharmacy (ACCP), as “a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention” (ACCP, 2012). It can be concluded that clinical pharmacy needs different professional work and skills toward the patient which can be optimized by encouraging more cooperation between pharmacists and other health care staff to reach desired outcomes. For clinical pharmacist, it is necessary to know and decide the goal of therapy, best drug choice, choosing between drug alternatives, risks and risk – benefit ratio, knowledge of adverse drug events (ADE) and drug interactions. In addition, clinical pharmacists should be well aware on how to use the drug (Buch, 2010).

The main aim of this work is to determine the effect of the presence of a Clinical Pharmacist on the cost of drug therapy in Intensive Care Unit (ICU).

2. Method

This study was carried out at Al-Hussein hospital at Royal Medical Services (RMS) in Amman, Jordan. It is considered to be a comparative study between the consumed quantities of two different groups of drugs: Anti-infective and Cardiovascular drugs, which are considered the most frequently used in ICU. Parenteral dosage form was selected because it is used for the majority of patients and it is the most expensive dosage form. The data were collected from the ICU pharmacy records covering two periods:

1st period: from August 2009 until May 2010, where no Clinical Pharmacist was present in the ICU.

2nd period: from June 2010 until March 2011, where a Clinical Pharmacist was present in the ICU.

The average purchasing price of each drug was elicited from RMS orders and tenders in 2009 and 2010. The total cost of each drug was calculated by multiplying the average purchasing price with the total consumed quantities of that drug. The sum of all drugs’ total cost in each group represents the total cost of that group. The difference in the total cost of each group between the two periods, i.e. saving was calculated. The sum of savings of both groups represents the total reduction of drug therapy.

3. Results

3.1. Drugs consumption changes

The consumed quantities in the absence (1st period) and presence (2nd period) of Clinical Pharmacist, the difference in consumption between the two periods and the reduction percentage for the studied drug groups are shown in details below.

3.1.1. Anti-infective drugs

Table 1 shows the total consumed quantities for the most frequently used Anti-infective drugs in presence and absence of Clinical Pharmacist. It also shows the change in consumed quantities and the percentage of these changes which ranged between 23.3% and 79.6%. The highest reduction percentage was ranked by Flucloxacillin; the average for the reduction percentage was 44.7%. All values were found to be significantly different (P ⩽ 0.01).

Table 1.

Consumption of Anti-infective drugs in the two periods.

No.	Drug	Consumption in 1st period	Consumption in 2nd period	Difference in consumption	Reduction percentage (%)
1	Imipenem & cilastatin	4735	3633	−1102	23.3
2	Benzyl penicillin	528	360	−168	31.8
3	Metronidazole	3958	2677	−1281	32.4
4	Vancomycin	3476	2268	−1208	34.8
5	Fluconazole	690	349	−341	49.4
6	Acyclovir	531	339	−192	36.2
7	Amikacin	2500	1586	−914	36.6
8	Ceftazidime	3607	2230	−1377	38.2
9	Gentamicin	1472	874	−598	40.6
10	Cefepime	1211	692	−519	42.9
11	Tazobactam	4502	2370	−2132	47.4
12	Cefotaxime	2907	1409	−1498	51.5
13	Ciprofloxacillin	334	157	−177	53.0
14	Ceftriaxone	5186	2385	−2801	54.0
15	Azithromycin	151	54	−97	64.2
16	Flucloxacillin	3804	775	−3029	79.6

3.1.2. Cardiovascular drugs

The most frequently used drug in this group was Furosemide while the least commonly used was Nimodipine as shown in Table 2. The highest value for reduction percentage was for Hydralazine (70.7%), and the lowest was for Furosemide (8%), the average for reduction percentage was 37.5%. All values were found to be significantly different (P ⩽ 0.01).

Table 2.

Consumption of Cardiovascular drugs in the two periods.

No.	Drug	Consumption in 1st period	Consumption in 2nd period	Difference in consumption	Reduction percentage (%)
1	Furosemide	13599	12487	−1112	8.2
2	Nitroglycerin	5380	4600	−780	14.5
3	Adrenaline	5855	4520	−1335	22.8
4	Dopamine	5962	4360	−1602	26.9
5	Alprostadil	587	426	−161	27.4
6	Labetalol	951	680	−271	28.5
7	Heparin	1575	1037	−538	34.2
8	Dobutamine	188	113	−75	39.9
9	Nimodipine	88	50	−38	43.2
10	Nor-adrenaline	1946	650	−1296	66.6
11	Tinzaparin	969	317	−652	67.3
12	Hydralazine	605	177	−428	70.7

3.2. Change in the cost

The total cost of each group was calculated depending on the total consumed quantity and the average purchasing price of each drug.

The difference i.e. saving in the total cost of consumed drugs between the 1st period and 2nd period is clearly evident as shown in Table 3. The total reduction of drug therapy cost after applying Clinical Pharmacy practices in ICU was 149946.79 JD (211574.92 USD) which represent an average saving of 35.8% against the cost of the 1st period in the study.

Table 3.

Total cost difference in the two periods.

Drug group	Total cost of 1st period (JD⁎)	Total cost of 2nd period (JD⁎)	Difference i.e. saving (JD⁎)	Difference (%)
Anti-infectives	324060.40	189150.20	134910.20	41.6
Cardiovascular	50122.42	35085.83	15036.59	30.0

^⁎JD: Jordanian Dinars, 1JD = 1.411 USD (conversion rate valid August 2011).

4. Discussion

ICU patients are critically ill patients and their treatment is challenging as they usually have more than one condition, altered organ functions and require many drugs. These patients require ‘polypharmacy’ to help in their condition. However the use of drug combinations brings risks as these combinations may contribute to ADE, complications, and drug interactions. In such an environment, the presence of a Clinical Pharmacist with thorough knowledge of clinical management of ADE, pharmacokinetics, pharmacodynamics, drug–drug and drug–food interactions could promote the rational use of drugs, and thus reduce the cost of drug therapy. The studies which were carried out in this field suggest that savings can be substantial (Maclaren et al., 2006). Seventeen years ago the ACCP estimated that a benefit of 16.70 USD is realized for every 1.00 USD invested in Clinical Pharmacy programs (Saokaew et al., 2009).

This study has also demonstrated the cost effectiveness for the presence of a Clinical Pharmacist in the ICU of a major hospital in Jordan. The study shows that applying Clinical Pharmacy practices results in a significant decrease of selected drugs consumption as shown in Tables 1 and 2. It must be stressed out that there were no changes in the study parameters during the two periods except the presence of Clinical Pharmacist. It can be concluded that the reduction in consumption is due to accurate application of Clinical Pharmacy practices, which include patient data collection and evaluation, correct documentation, identifying and solving drug related problems and reactive clinical interventions.

The reactive interventions that were carried by a Clinical Pharmacist and brought about such changes may have been; changing the drug administration route, discontinuing unnecessary drug, for example duplicate therapy or unnecessary antibiotics combinations, change dosing time, recommending another cheaper therapy and monitoring treatment parameters, teaching the nursing staff to decrease drug waste and decrease medication errors.

The decrease in cost is correlated with a reduced consumption rate. This leads to decrease in the total cost of drug therapy for ICU patients as shown in Table 3. A Clinical Pharmacist could reduce the total cost of treatment indirectly by decreasing the annually purchased quantity of drugs, storage and delivery of these drugs.

These cost savings show that the presence of Clinical Pharmacists in an integrated health care system is both important financially as well as clinically. A greater overall reduction in the cost of drug therapy could be achieved if results were extrapolated to the hospital setting as a whole or if the data were collected for all drugs that are used in ICU.

5. Conclusion

Applying Clinical Pharmacy practices in ICU proved to reduce the cost of drug therapy in addition to improving the quality of health care provided to patients. When such practices are applied to the whole hospital system it may lead to better health care services provided to patients as well as reducing the drug budget, both of which would be beneficial for the RMS and other health care systems.