APTI ijopp - Indian Journal of Pharmacy Practice

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Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009procedures or laboratory monitoring. The panel then mentioned in Indian Drug Review (IDR) was considered.confirmed or rejected the intervening pharmacist's All those changes made in drug therapy were noted fromassessment and quantified the resultant changes. The patients' medication administration records. The totalcriteria for assessment and quantification of these drug cost was calculated by considering only the actualchanges were based solely on review of the individual drug cost based on drug, dose administered, frequencycase and the collective decision of the panel. The panel and duration of therapy. Administration charges, syringesdid not assess the interventions perceived to result only in and reconstitution solutions, and discharge medicationsa change in drugs but instead intervening pharmacist were excluded from the cost assessment procedure. Costcalculated the impact on drugs-costs. Actual cost at the of injections was calculated as whole vials. If a dosestudy site was considered for the purpose of analysis of range was prescribed, cost was based on the average doseimpact on cost savings on length of stay, probability of2administered.readmission and evaluation of changes to lab monitoring. Annualized Cost SavingsCost Evaluation of Probability of Readmission and Annualized cost savings were calculated byLength of stayextrapolating the seven months' data and their associatedThe probabilities of readmission were estimated based cost saving over a year.on the probability (expressed as percentage likelihood) RESULTSof a readmission event occurring without the interventionA total of 3315 cases were followed and reviewed in thecompared with the probability of a readmission after themedical ward over seven months period. Of the cases2reviewed, 261 drug related problems were identifiedintervention has occurred. Costs were then calculated bymultiplying this probability with the average cost of the from 189 patients. The incidence of DRPs was found totreatment for specific disease costing at study site.be 7.9 per 100 patients followed. Average DRPs perThe panel quantified the impact of each intervention on prescription was 1.4 (range: 1 to 5). Majority [57.8 %LOS by estimating the change in the number of days in (n=109)] of patients were male. The average age of theeither a general medical ward or high dependency wards patients was 49.8 + 13 (Mean +SD) years (range: 19 to 80(Incentive Care Unit, Coronary care unit, Emergency years). Majority (52.8%) of DRPs occurred in the agewards). The change in LOS was based on likelihood of group of 41- 60 years. The demographic details of thechanges in LOS occurring if the intervention was not study patients are summarized in Table 1.2done. The local independent clinical panel decided as to The most common drug related problem was drug usesub-classification of the wards based on individual case. without indication, which accounted for 18% (n=47) ofThe cost impact of changes in LOS was then calculated total DRPs followed by improper drug selection [14%based on average ward costs for the particular ward as (n=36)] and subtherapeutic dose [14% (n=36)].The typesexisted at the study site.of drug related problems are summarized in Table 2.Laboratory Monitoring Changes and Medical Of the total interventions, the significance levelProcedures'moderate' was found to be high (60%) followed byThe independent clinical panel examined the changes to significance level 'minor' (29%). The significance levellaboratory monitoring or medical procedures and of drug related problems is represented in Table 3.allocated a probability of the event being changed as a The most frequent suggestion provided by theresult of the intervention. The cost impact was then intervening pharmacist was cessation of drug [20 %calculated by multiplying this probability by the study (n=53)] followed by addition of drug [14% (n=37)].site's costs for the particular medical procedure or Change in drug dose accounted for 13% (n=33) of totallaboratory test.suggestions provided. Suggestion related toEvaluation of Drug Costpharmaceutical aid was found to be least [2% (n=4)].The impact of pharmacist intervention on drug cost was Various suggestions provided by the interveningassessed by considering change in the medication orders pharmacist are summarized in Table 4.that occurred during hospital stay. The discharge The acceptance rate of intervening pharmacist'smedications of the patient were not considered for cost suggestions was found to be 87 % (n=227). Of these,2evaluation. For the analysis of drug costs, intervening changes in drug therapy was observed in 81% (n=183) ofpharmacist referred latest issue of Current Index of accepted suggestions. The total time spent by theMedical Specialities (CIMS). If the drug costs for the intervening pharmacist in preparing, undertaking andparticular drug was not available in CIMS, then cost documenting all interventions was 106 and 25 minutes38
Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009[average 12.5 minutes; range: 2 to 60 minutes].gastritis associated with use of antibiotics and NSAIDs.Of the total interventions, 46% (n=118) of interventions However, where appropriate, after interveningbelonged to drug therapy decision-making level 1 pharmacist's intervention rabeprazole was withdrawn(Corrective) followed by level 4 (Proactive) accounting from the patient's therapy.to 30% (n=79). The Pharmacist's involvement in drug Improper drug selection [14%] was the second mosttherapy decision making is presented in Table 5.common DRP observed. This finding coincides with theA total of 128 interventions resulted in decrease in cost of3study conducted by Gurumurthy Parthasarthi et altherapy while 33 interventions incurred additional cost. wherein, it reported improper drug selection [17%] as theThe total net cost savings was Indian Rupees (INR) second most common DRP that occurs in medicine27,233.55/=. This included savings of INR 5590.50/= forwards. The high incidence of improper drug selectionreduction in length of stay, INR 9079.85/= formay be attributed to lack of standard treatment protocolreadmission reduction, INR 476.20/= for laboratoryin the hospital, poor history taking etc. In one incidence,monitoring and INR 12,087.00/= for drugs. The impacthypertensive patient with a history of diabetes wasof pharmacist-initiated changes to drug therapy and theiradministrated with Beta-blocker owing to lack ofassociated cost savings is presented in Table 6.documentation of patient's medical history. Later, whenDISCUSSIONIn India, clinical pharmacy service is an emergingintervening pharmacist reviewed the case, it was3discipline . Clinical pharmacy service is to optimizeobserved that the patient was also diabetic andpatient outcomes by working to achieve the bestappropriate intervention was made as beta blockers may12possiblequality use of medicines. It has been shown thatmask the hypoglycemic side effect of anti-diabetics.the clinical pharmacy activities reduce the drug relatedFailure to receive drug was accounted for 5% (n=14) ofproblems related hospitalization, probability of readthetotal DRPs. In few cases, it was due to economic2,3 constraints of the patients that led to non-procurement ofmission and total cost of drug therapy. This prospectiveprescribed medicines while in few other cases it was duestudy was carried out to assess and quantify thepharmacist-initiated changes in drug therapy of intotake the medications for unknown reasons. Other typesto shift change of nursing staff and reluctance of patientspatients of a tertiary care teaching hospital.In our study, DRPs were high (52.8%) in patients aged of DRPs including drug duplication and class duplicationbetween 41and 60 years. Of the 189 patients, DRPs were majority due to availability of more than 80,000commonly observed in male patients (57.8%). This formulations of drugs in Indian market with different3finding might be due to increased medication use owing brand names leading to confusion. This error can beto their multiple co-morbidities. Majority (71.4%) of minimized by prescribing generic names and also bypatients received more than six drugs per day and hence reviewing and re-checking of medication order regularlyincreased risk of occurrence of drug related problems. prior to drug administration.Regular review of patients' medication use may Of the 261 DRPs, 29% (n=75) were rated to be 'minor',potentially decrease the drug related problem. 13 60% (n=157) were 'moderate' and 11% (n=29) wereDrug use without indication [18% (n=47)] was the most 'major' significance of interventions. This findingcommon DRP observed followed by improper drug3correlates with a study that reported 49% ofselection [14% (n=36)]. This observation is in contrast interventions as 'moderate' significance. The 'moderate'with the study carried out by Gurumurthi Parthasarthi et significance level is the level of problems requiring3al , in which inappropriate dosing accounted for highest adjustments, which are expected to enhance(31%) followed by improper drug selection (17%). Few effectiveness of drug therapy producing minor reductiondrugs often used without indication included in patient morbidity or treatment costs. In our study, forRabeprazole, Paracetamol and Ranitidine. Although anti example, patient experienced severe diarrhea [presencesecretory agents often used as prophylaxis, especially in of signs of dehydration with abdominal pain and cramps]patients with previous history of acid peptic ulcer after receiving Clindamycin. After having assessed thedisease, the agents were prescribed while there was no ADR, the intervening pharmacist informed physiciansuch indication. A study conducted by David L. Whaley about the possible Clindamycin induced diarrhoea and14et al reported that gastrointestinal agents were the major sought for the cessation of drug. Thus the timelyclass of drug prescribed in a hospital. In our study, the use intervention by intervening pharmacist might haveof proton pump inhibitor was to prevent the possible resulted in reduction in hospital stay and hence the cost39
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