The role of the pharmacist in the determination of ... - IOS Press

Pharmaceuticals Policy and Law 12 (2010) 313–319 DOI 10.3233/PPL-2010-0305 IOS Press

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The role of the pharmacist in the determination of pharmacotheraphy costs: Ischemic cardiopathy patients with smoking habits Nadia Vanina Riparia,∗ , Elena Maria Vegab, Mar`ıa Eugenia Elorzac , Nebel Silvana Moscosoc, Daniel Palma Santiagod and Nadia Budassie a CONICET

– Universidad Nacional del Sur, Buenos Aires, Argentina Nacional de Córdoba, Córdoba, Argentina c CONICET – Universidad Nacional del Sur, Buenos Aires, Argentina d CONICET – Universidad Nacional de C´ ordoba, Córdoba, Argentina e Universidad Nacional del Sur, Hospital Provincial Dr. Jos´ e Penna, Buenos Aires, Argentina

b Universidad

In the last decades the pharmacist has played a main role in the policies of costs containment in the health sector. The present study has been designed to assess this role in the costs containment of the pharmacological treatments of patients at a Coronary Care Unit (CCU) of a public hospital in Argentina, through an analitic and retrospective study. It has been observed that the pharmacist could determine in all the service a saving of $ 3,393.03 buying the prescriptive drugs at minimum prices during the analized period. However, it has been proved that there are costs which the pharmacist cannot modify, as in the case of certain risk factors that may increase the pharmacological costs in the treatment of a pathology. This cost variation has been proved in ischemic cardiopathy patients with smoking habits. Keywords: Role of the pharmacist, costs containment, ischemic cardiopathy, smoking habits

1. Introduction In the last decades the pharmacist has ceased to be a drug dispenser in order to be a drug theraphy manager [1]. Different authors suggest that the action of the pharmacist in the policies of costs containment, hospital costs, and domestic economy is significant in this new context [2]. Arroyo Conde et al. [3] assert that the pharmacist can reduce the total costs in hospitals. S. TroyMcMullin et al. [4] acknowledge that the pharmacist‘s recommendations improve medical care quality and reduce the expenditure on drugs. Nevertheless, the pharmacist can affect just a proportion of the pharmacological treatments costs. Those who work in hospital institutions can influence these costs through an efficient management of (drugs) acquisition as well as an efficient management of pharmacotheraphy1. Likewise, those who work in community pharmacies ∗ Corresponding

author. Tel.: +54 291 4595101 2740; E-mail: n [email protected]. its importance, the potencial savings from an efficient management in pharmacotherapy have not been estimated. 1 Despite

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N.V. Ripari et al. / Role of the pharmacists in the determination of pharmacotheraphy costs

can reduce their patients’ expenditure through the effective counselling of available drugs. Among the costs which cannot be controlled by the pharmacist we can mention those related to the risk factors inherent in each patient, sedentary behaviours, obesity, smoking, and stress, among others. These conditions can increase the average costs of a pathology, even if the pharmacist is really efficient (supplying the lowest-price pharmaceuticals in the market) [5–7]. This study aims to analyse the rol of the pharmacist in the costs containment of the pharmacological treatments given to 319 patients treated between 2008 and 2010 in the Coronary Unit Service of a Public Hospital in Argentina. We have also analysed the pharmacists’ limitations due to the influence of risk factors. For the analysis of the costs that are likely to be modified by the professional, all coronary care unit (CCU) costs have been considered, whereas for the case of non-modifiable costs, the ischemic cardiopathy patients with smoking habits have been considered.

2. Methods and materials An analitical and retrospective study of the costs of pharmaceuticals prescribed to inpatients at a CCU of the Dr. Jose Penna Hospital in the city of Bahia Blanca between March 2008 and May 2010. 63 out of the 382 patients treated during the studied period were excluded, since their data and pharmacological treatments were incomplete. The other 319 patients were classified according to the International Classification of Diseases 10th edition (ICD-10). The prescribed drugs have been grouped, according to the Anatomical Therapeutic Chemical System into 8 categories: cardiovascular system (C), alimentary tract and metabolism (A), nervous system (N), systemic hormonal preparations, excl sex hormones and insulines (H), antiinfective for systemic use (J), respiratory system (R), musculo-skeletal system (M), and genito urinary system and sex hormones (G). The costs of the different drugs have been obtained from the market prices between September and October 2010 depending on the various laboratories and presentations [8–10]. The following variables have been estimated in all patients: sex, age, inpatient days, health care coverage, discharge diagnosis and the risk factors smoking,diabetes, arterial hypertension and/or dyslipidemia. In order to improve the symmetric conditions and to reduce the extreme values of the dependent variable its log transformation has been used. To prove there are significant differences in the costs among groups the Mann Whitney and KruskallWallis non parametric statistical techniques have been used. Descriptive statistical methods and statistical tests from the software SPSS 15.0 have been used to analyse the data.


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Table 1 Descriptive statistics

Age Isquemich cardiomiopathy diagnosis (n = 153) Without health care coverage

Coronary patients (n = 319) Women (n = 59) Men (n = 260) 18% 82% % mean ± DE % mean ± DE 64.11 ± 14.49 52.86 ± 9.17 11.39 88.60 55.93

80.76

Source: Developed by the authors based on information from the CCU.

3. Results The outstanding descriptive statistics from the studied sample can be seen in Table 1. Ischemic heart diseases is the most frequent diagnosis (I20-I25 in the ICD-10 categories) being more prevalent in men. The mean hospital stay was 7 days (17.21 days). The elevated dispersal is due to the fact that 9 patients were hospitalized more than 30 days, out of these cases the mean stay is 5 days. The patients were prescribed on average 4.61 (± 1.94) different drugs. The groups of drugs mostly used, according to the ATC classification, belonged to C (99%), A (25.4%), N (9.4%).The rest of the drugs were only taken by less than 5% of the patients. Through the analysis of pharmacological costs, it has been stated that 8 patients were excluded from the research for being statistically considered outliers. Taking the costs of the pharmacological treatments of all patients treated at the Coronary Care Unit between 2008–2010 as a starting point, we have analysed just the costs likely to be modified by the pharmacist. Different authors found out that the pharmacist’s interventions at an intensive care unit produces a potential saving in the total costs of drugs [11,12]. However, for Miragaya [13] the pharmaceutical care services given to coronary patients through pharmacotheraphy constitute a low saving, especially in the ischemic cardiopathy, where the pharmacist intervencion in the prescription does not alter the expenditure in the drugs of the cardiovascular system group. In our study it was determined that the total cost of drugs at the CCU has been $ 18,686.87 (U$S 4,718.90) to minimum prices and $ 32,123.30 (U$S 8,111.94) to maximum prices. Thus, the pharmacist’s efficient purchase of drugs would entail a potential saving of $ 13,436.43 (U$S 3, 393.03). The drugs of the cardiovascular system represent 93% of the whole pharmacological cost of the CCU. Likewise, this is the group with most variability in prices, with a cost of $ 12,994.99 (U$S 3, 281.56) to minimum prices, and of $24,158.90 (U$S 6, 100.73) to maximum prices. The potential saving due to the efficient acquisition of cardiovascular drugs is estimated to be $11,426.01 (U$S 2, 285.35). It has been proved that the pharmacist’s decisions are economically relevant due to the great variability in prices of the national drug market, related to the existence of

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Fig. 1. Graph N◦ 1: Box-plot: Cost log dependig on smoking habit. Source: Developed by the authors based on information from the CCU.

different laboratories and multiple presentations. This is particularly so in Argentina after the enactment of the law 25.649 in the year 2002, which makes doctors prescribe drugs according to their generic name, with the possibility of suggesting just some commercial names. This policy enables the pharmacist to offer all the commercial brands of the same active principle to the citizen, so the citizen can then choose according to his preferences. However, the professional could reduce costs if his recommendations are endorsed by scientific evidence that guarantees the effectiveness of the alternative drugs for the same treatment. According to Bero et al. [14] more costs evaluations that guarantee the effects of the pharmacist’s interventions are needed. Laurant et al. [15] suggest that the pressure to maintain costs have redefined the professional pharmacist’s roles, even though there is no sufficient scientific evidence of the economical benefit of their interventions. To implement economical evaluations it is essencial for the profesional to have certain knowledge of economics to interpret and make cost-effectiveness or cost-utility cost-minimization analyses. This knowledge could be acquired in the undergraduate studies of the carrers in pharmacy. Nonetheless, from all the universities that educate pharmacy professionals (7 are private universities and 11 are public) just 2 (one public and the other private) have incorporated required economic subjects in the curriculum and three universities (all of them public) suggest economic and


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Table 2 Descriptive statistics depending on the smoking habit

Smokers Ex-Smokers Non smokers

Schemic cardiopathy patients (n = 153) Women (n = 16) Men (n = 137) n % n % 6 37.50 63 41.61 4 25.00 42 27.74 6 37.50 48 30.66

Source: Developed by the authors based on information from the CCU.

management contents as elective subjects2 . As regards the non modifiable costs by the pharmacist, it has been observed that certain disease patterns could alter drugs consumption patterns. This is the case of modifiable or non modifiable risk factors inherent in each patient. Smoking is especially one of the risk factors that contributes to cardiovascular diseases and increases their costs [16]. Different authors analyse the costs associated with this habit and prove that abandoning this habit is the best cost-efficiency intervention for cardiovascular disease prevention [17]. According to Fishman [18, 19] this habit is associated with a better use of health services by smokers and exsmokers in relation to those who have never smoked. He demonstrates that, in a short term, ex-smokers incur upper costs in relation to smokers, but in the long term, the accumulated costs in the health area are lower for ex-smokers. In our study we analyse the effect caused by the smoking habit in the pharmacological costs variations of the ischemic cardiopathy patients. This diagnosis has been selected for being the most prevalent (153 patients) during the studied period3 . The cost of the pharmacological treatment has been estimated for all patients. The patients that smoked at least one cigarette at their CCU admissions were classified as ‘smokers’, those who did not have the smoking habit but at some time had experienced it were classified as ‘ex smokers’, and those who had never had the habit as ‘non smokers’. The statistics of the schemic cardiopathy patients with smoking habits according to their sex are summarised in Table 2. There is a high prevalence of smokers from both sexs, followed by the non smokers, being the ex smokers the least. The mean of the daily pharmacological cost for the smokers, non smokers and ex smokers is $11,69 (U$S 2.95), $10,82 (U$S 2.73) y $7,98 (U$S 2.01) respectively. These costs are $350,70 (U$S 88.56), $324,60 (U$S 81.96) and $239,40 (U$S 60.45) monthly. The pharmacological cost log presents upper central values and a larger dispersión for ex-smokers (Graph No 1).

2 This information has been taken from the curriculum of the careers in pharmacy in Argentina. In each case, it has been recorded the existence of subjects related to the economics and management areas. 3 In all the an´ alisis, it is assumed that the professional’s efficient performance buying at the lowest costs.

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The Mann Whitney and Kruskall-Wallis non parametric statistical method has been used. The results show there are significant differences in the mean costs depending on the smoking habit category (p-value 0.034). Analysing the risk factors, diabetes, hipertension, and dyslipidemia, it has been observed that the diabetic patients incur statistically different costs in the three gropus (p-value 0.005),whereas for the patients with hipertension and dyslipidemia there is no sufficient evidence against the equal costs (p-value 0.642, 0.653 respectively).

4. Conclusion In the last decades the pharmacist has had a main role in the policies of costs containment in the Health Sector. However, in this research it has been observed that just a few costs are likely to be modified by the professional. It has been observed that the pharmacist could achieve a saving of $13.436,43 (U$S 3,393.03) from the purchase of prescribed drugs at the minimun price in the studied period. This has been done taking into account the pharmacological treatment total costs of the patients treated at a Coronary Care Unit. Moreover, it has been proved that certain costs in ischemic cardiopathy patients are not likely to be modified by the professional, due to the influence of certain risk factors such as smoking, which could increase the regular pharmacological costs in the treatment of the pathology.

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