Full costs of dispensing and administering fluorouracil chemotherapy for outpatients: A microcosting study

BackgroundAlthough full costs (including direct and indirect costs) that incurred during the process of chemotherapy administration should be measured, many studies estimate only direct labor and medication costs associated with various chemotherapy delivery systems.ObjectivesTo estimate the total costs for dispensing and administration of fluorouracil when administered with leucovorin, by intravenous infusion or bolus, using a microcosting approach from the perspective of a provider or health system.MethodsA time-and-motion study was used to measure the time spent by (1) pharmacy staff in the handling, admixture, and dispensing of fluorouracil and (2) patients in the clinic. The study was performed at The Cancer Institute of New Jersey for an 8-month period. Costs of dispensing and administering fluorouracil were calculated per patient visit on the basis of resources used in the processing of fluorouracil and time spent by pharmacy staff and patient. All costs were standardized to 2005 dollars.ResultsA total of 275 observations were made, and 74 (26.9%) of these were associated with fluorouracil-based chemotherapy. Pharmacy staff spent an average of 11 minutes for bolus fluorouracil with leucovorin infusion (fluorouracil/LCV-IV) and 8 minutes for bolus fluorouracil with bolus leucovorin (fluorouracil/LCV-B). Patients who received fluorouracil/LCV-IV spent an average of 203 minutes in the clinic, whereas patients who received fluorouracil/LCV-B spent 110 minutes. The average cost of administering fluorouracil/LCV-IV was $933, which comprised drug costs ($279), dispensing costs ($189), and administration costs ($465). The average cost of fluorouracil/LCV-B was $474, which comprised drug costs ($65), dispensing costs ($141), and administration costs ($268).ConclusionsThis is the first study to formally demonstrate the high cost of administering the injectable form of fluorouracil chemotherapy with leucovorin, despite relatively low drug acquisition cost. Therefore, reimbursement rates for fluorouracil should be calculated in such a way that covers all costs, including overhead costs for the department.     

Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals

This study evaluated direct relationships and associations among clinical pharmacy services, pharmacist staffing, and total cost of care in United States hospitals. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field and the 1992 National Clinical Pharmacy Services Database. A multiple regression analysis, controlling for severity of illness, was employed to determine the relationships and associations. The study population consisted of 1016 hospitals. Six clinical pharmacy services were associated with lower total cost of care: drug use evaluation (p=0.001), drug information (p=0.003), adverse drug reaction monitoring (p=0.008), drug protocol management (p=0.001), medical rounds participation (p=0.0001), and admission drug histories (p=0.017). Two services were associated with higher total cost of care: total parenteral nutrition (TPN) team participation (p=0.001) and clinical research (p=0.0001). Total costs of care/hospital/year were lower when any of six clinical pharmacy services were present: drug use evaluation $1,119,810.18 (total $1,005,589,541.64 for the 898 hospitals offering the service), drug information $5,226,128.22 (total $1,212,461,747.04 for the 232 hospitals offering the service), adverse drug reporting monitoring $1,610,841.02 (total $1,101,815, 257.68 for the 684 hospitals offering the service), drug protocol management $1,729,608.41 (total $614,010,985.55 for the 355 hospitals offering the service), medical rounds participation $7,979,720.45 (total $1,212,917,508.41 for the 152 hospitals offering the service), and admission drug histories $6,964,145.17 (total $208,924,355.10 for the 30 hospitals offering the service). Clinical research $9,558,788.01 (total $1,013,231,529.06 for the 106 hospitals offering the service) and TPN team participation $3,211,355.12 (total $1,027,633,638.43 for the 320 hospitals offering the service) were associated with higher total costs of care. As staffing increased for hospital pharmacy administrators (p=0.0001) and clinical pharmacists (p=0.007), total cost of care decreased. As staffing increased for dispensing pharmacists, total cost of care increased (p=0.006). Based on this total cost of care model, optimal hospital pharmacy administrator staffing was 2.01/100 occupied beds. Staffing for dispensing pharmacists should be as low as possible, and definitely fewer than 5.11/100 occupied beds. Staffing for clinical pharmacists should be as high as possible, but definitely more than 1.11/100 occupied beds. The results of this study suggest that increased staffing levels of clinical pharmacists and pharmacy administrators, as well as some clinical pharmacy services, were associated with reduced total cost of care in United States hospitals.     

Staffing and the cost of clinical and hospital pharmacy services in United States hospitals.

A survey was mailed to pharmacy directors at all United States acute care medical-surgical hospitals that related to staffing and cost components of hospital pharmacies and clinical services. Cost information was evaluated as both unadjusted and adjusted for severity of illness using the Health Care Financing Administration's Medicare case mix index (CMI). Unadjusted drug costs/occupied bed/year were $13,350+/-6927, a 36% increase over 1992 and a 112% increase over 1989, with statistically significant differences observed by geographic region, hospital size, hospital ownership, and drug delivery system. Annual median pharmacist salary costs/patient associated with centrally based clinical pharmacy services were drug use evaluation $111, in-service education $20, drug information $117, poison information $24, and clinical research $35. Annual median pharmacist salary costs/patient associated with patient-specific clinical services were drug therapy monitoring $5, pharmacokinetic consultation $8, patient counseling $6, medical rounds $4, admission drug histories $7, and drug therapy protocol management (prescribing) $9. Drug costs continue to increase at double-digit rates. Substantial differences exist among various regions of the country with salary and specific cost components. Registered nursing staffing is increasing at twice the rate of pharmacists staffing increases.     

Cost of inpatient pharmaceutical services in U.S. hospitals in 1989.

The results of a spring 1989 national survey of hospital-based pharmacy services are reported; this article focuses on the cost structure of services. A questionnaire was sent to 2112 hospitals, comprising half of U.S. acute-care general medical or surgical hospitals with 50 or more licensed beds. Cost results were evaluated both as unadjusted data and as data adjusted with the case mix index (CMI). The survey had a response rate of 56% (1174 usable responses). Both pharmacy cost information and the CMI were obtained for 1000 hospitals. Mean +/- S.D. unadjusted medication costs per occupied bed were $6744 +/- $3048 and varied significantly with geographic region. Mean +/- S.D. pharmacist salary costs per full-time equivalent (FTE) were $38,432 +/- $8,550 and differed with geographic region, hospital ownership, the pharmacy drug delivery system, and the pharmacy director's education. Pharmacist salary costs associated with centrally based clinical pharmacy services ranged from a high of $60 per occupied bed per year for drug information services to a low of $15 for inservice education. The state with the highest mean +/- S.D. pharmacist annual salary per FTE was California ($45,900 +/- $11,037); the state with the lowest annual salary was Indiana ($29,637 +/- $7,110). A 1989 survey of clinical pharmacy services provided comprehensive data on complex cost structures.     

Microcost analysis of inpatient dispensing and administration of oral solids

The labor cost of dispensing, administering, and monitoring unit dose oral solid dosage forms (UDs) in a large teaching hospital was determined by microcost analysis. The costs associated with UDs dispensed by the midnight central pharmacy and by a satellite pharmacy were evaluated by use of both work-sampling and time-and-motion studies. Pharmacy personnel activities were classified as direct, auxiliary, or nonproductive. A nursing productivity index was used to determine the nursing time consumed in the administration and monitoring of UDs. The pharmacy labor cost was lowest ($0.14 each) for UDs dispensed from the central pharmacy in the 24-hour medication cart. For each UD that was not dispensed in the 24-hour cart, the labor cost was $0.25 for the central pharmacy and $1.37 for the satellite pharmacy. It took nurses 223.8 sec to administer and monitor a scheduled UD, for a cost of $0.82. The total nursing time spent per nonscheduled UD for administration and monitoring was 574.2 sec; the cost was $2.11. Microcost analysis can be used to isolate the costs of dispensing oral solids in an inpatient setting.     

Comparative analysis of drug distribution costs for controlled versus noncontrolled oral analgesics

Total costs for controlled substance oral analgesics and non-controlled analgesics were compared for patients at a 548-bed university hospital. During 1983, all cost elements involved in drug delivery (excluding large-volume parenterals) were identified. Direct and indirect pharmacy labor costs were determined. Personnel costs were calculated from time studies of nurses (in 1979-80) and pharmacy technicians (in 1982). Other pharmacy costs, based on the hospital's 1982 data, included inventory holding costs, computer services, supplies, and drug acquisition costs. Costs were calculated for four oral analgesics--acetaminophen with codeine, aspirin with codeine, ibuprofen, and zomepirac sodium--used during a 30-day period in 1981. For all medications, total average cost per dose for 1,949,418 doses was $2.44, of which 41% was drug acquisition cost. Personnel costs for pharmacy and nursing accounted for 43% and 11%, respectively, of total costs. For 46% of 5111 oral analgesic doses, frequency of administration was at least four times daily. Average purchase cost per dose for the oral analgesics was $0.15, while total costs for the controlled and non-controlled drugs were $1.02 and $0.50, respectively. For the four oral analgesics in this study, cost was affected by dosage schedule and controlled or noncontrolled status. Calculation of the total average cost per dose is useful in projecting annual costs and in identifying areas for cost reduction.     

Impact of a pharmacist on drug costs in a coronary care unit.

The impact of clinical pharmacy services on direct drug costs in a coronary care unit (CCU) was studied. An observational, nonrandomized study was conducted on all patients admitted to the CCU to evaluate the impact of clinical pharmacy services on direct drug costs. Clinical pharmacy services were introduced into the CCU in July 1998. Patient characteristics, mean drug costs per admission, mean drug category costs per admission, and total hospital costs per admission were determined for October 1997 to June 1998 (nonintervention period), July 1998 to March 1999 (intervention period 1), and April 1999 to December 1999 (intervention period 2). The Clini-Trend program was used to estimate the total reduction in drug costs associated with documented pharmacist interventions from January to December 1999. Mean patient age, sex, admitting diagnosis-related group, Medicare case-mix index, ventilator days, length of stay, and number of deaths did not differ significantly among the three study periods. Mean +/- S.D. drug costs per admission for the nonintervention period were $374.05 +/- $75.51. With the introduction of clinical pharmacy services, mean +/- S.D. drug costs per admission were $381.94 +/- $66.16 (p > 0.1 for intervention period 1 compared with the nonintervention period) and $233.74 +/- $84.16 (p = 0.002 for intervention period 2 compared with the nonintervention period). From January to December 1999, 4151 pharmacist interventions were documented. The estimated reduction in drug costs associated with the interventions totaled $372,384. A pharmacist's clinical services in the CCU allowed for significant estimated reductions in total drug costs.     

Clinical pharmacy services, pharmacist staffing, and drug costs in United States hospitals

We evaluated direct relationships and associations among clinical pharmacy services, pharmacist staffing, and drug costs in United States hospitals. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field and the 1992 National Clinical Pharmacy Services database. Multiple regression analysis, controlling for severity of illness, was employed to determine the associations. The study population consisted of 934 hospitals. Four clinical pharmacy services were associated with lower drug costs: in-service education, $77,879.19+/-$56,203.42 (a total of $48,518,735.37 for the 623 hospitals offering this service, p=0.016); drug information, $430,579.84+/-$299,232.76 ($90,852,346.24 for the 211 hospitals offering this service, p=0.015); drug protocol management, $137,333.67+/-$98,617.83 ($45,045,443.76 for the 328 hospitals offering this service, p=0.049); and admission drug histories, $213,388.21+/-$201,537.85 ($5,548,093.46 for the 26 hospitals offering this service, p=0.011). As staffing increased for hospital pharmacy administrators (p<0.0001), dispensing pharmacists (p<0.0001), and pharmacy technicians (p<0.0001), drug costs increased. As staffing increased for clinical pharmacists, drug costs decreased (p=0.018). The results of this study show that increased staff levels of clinical pharmacists and some clinical pharmacy services are associated with reduced hospital drug costs.     

Costs and savings of investigational drug services.

The costs and savings resulting from two pharmacy-based investigational drug services (IDSs) for fiscal year 1996-97 were studied. The costs and savings associated with IDSs at two joint institutions were calculated by adding the cost-avoidance figures (money that would most likely have been spent, but was not because of a specific intervention or program) to the money received from services charged to study investigators or patients and subtracting salaries and overhead costs. Only drugs for which the authors could obtain prices were used to calculate cost-avoidance figures. The number of doses of marketed drugs that were provided free or for which the pharmacy was reimbursed by a drug study sponsor between July 1996 and June 1997 was tabulated from pharmacy dispensing records for each study. Investigational drugs that were not marketed or for which no marketed alternative was available were not included in the cost-avoidance calculation but were included in the charges for IDSs. The total cost of IDSs at the two institutions was $249,112. Income (representing cost avoidance and payments received) totaled $2,958,774, giving the IDSs an overall saving of $2,709,662. The two disease categories with the largest cost-avoidance figures were AIDS and oncology. In total, there was a cost avoidance of $2.9 million in drug costs, which is equivalent to 8% of the institutions' annual drug budget for 1996-97. IDSs in two institutions accounted for a combined one-year saving of over $2.7 million, most of which was attributable to cost avoidance from not having to purchase study drugs.     

自动化建设给我院门诊药房带来的改变

目的:为国内大型医院自动化门诊药房的建设与发展提供参考。方法:采用快速出药、智能存储、批量上药及智能发药等设备对我院门诊药房进行自动化改造,分析门诊药房自动化改造后药品管理、调剂质量、药师工作效率等方面发生的改变。结果:门诊药房自动化优化了药品管理,有利于药品养护,加强了库存管理,解决了效期管理难题,实现了药品批号追踪;调剂差错由改造前的32.6件/周减少至改造后的11.3件/周,降低了65.3%;自动化药房设备参与了约90%的门诊处方调配,实现了药品调剂从"人等药"到"药等人"的转变,提高了工作效率,保障了患者的用药安全。结论:自动化有利于提高国内大型医院门诊药房的管理和服务水平。     

Subsidising patient dispensing fees: The cost of injecting equity into the opioid pharmacotherapy maintenance system

Introduction and Aims. Australian pharmacotherapy maintenance programs incur costs to patients. These dispensing fees represent a financial burden to patients and are inconsistent with Australian health‐care principles. No previous work has examined the current costs nor the future predicted costs if government subsidised dispensing fees. Design and Methods. A system dynamics model, which simulated the flow of patients into and out of methadone maintenance treatment, was developed. Costs were imputed from existing research data. The approach enabled simulation of possible behavioural responses to a fee subsidy (such as higher retention) and new estimates of costs were derived under such scenarios. Results. Current modelled costs (AUS$11.73m per month) were largely borne by state/territory government (43%), with patients bearing one‐third (33%) of the total costs and the Commonwealth one‐quarter (24%). Assuming no behavioural changes associated with fee subsidies, the cost of subsidising the dispensing fees of Australian methadone patients would be $3.9m per month. If retention were improved as a result of fee subsidy, treatment numbers would increase and the model estimates an additional cost of $0.8m per month. If this was coupled with greater numbers entering treatment, the costs would increase by a further $0.4m per month. In total, full fee subsidy with modelled behavioural changes would increase per annum government expenditure by $81.8m to $175.8m. Discussion and Conclusions. If government provided dispensing fee relief for methadone maintenance patients, it would be a costly exercise. However, these additional costs are offset by the social and health gains achieved from the methadone maintenance program.[Chalmers J, Ritter A. Subsidising patient dispensing fees: The cost of injecting equity into the opioid pharmacotherapy maintenance system. Drug Alcohol Rev 2012;31:911–917]     

Cost analysis of a satellite pharmacy

The cost-effectiveness of a satellite pharmacy that serves 100 beds in a 550-bed community teaching institution was determined. On one day six months before and one day six months after the satellite pharmacy was implemented, 30 patients were randomly selected for study from the 50-bed surgical-trauma unit and the 50-bed medical oncology unit served by the satellite. Data for the cost analysis were collected from the medical charts of these 60 patients; each patient's entire hospital stay was used for all calculations. Data collected included costs per patient day for drugs, i.v. therapy, and laboratory tests; total hospital costs per patient day; number of doses per patient day; and length of hospital stay. There were no significant differences in patient age or sex, length of hospital stay, or patient mix among patients studied before and after the satellite pharmacy was implemented. The cost per patient day for drugs was significantly less after the satellite pharmacy was implemented. A cost analysis based on this decrease in drug costs per patient day of $5.77 showed that an annual savings of $134,927 could be realized as a result of satellite pharmacy implementation. Implementation of a pharmacy satellite proved to be cost-effective, largely because of decreased drug costs.     

调剂费收费方式的国际经验介绍

目的：介绍主要国家（地区）调剂费的收费方式。方法：通过文献调查和网页搜索获得各国（地区）调剂费收费方式的资料。结果与结论：社会药店和医院门诊药房的药品调剂费的收取方式主要有按处方收费、按人头收费、按处方中药品数目收费等;医院住院药房药品调剂费一般和医疗服务打包进入病种收费．也有按照患者住院的床日数收费的。     

Costs and utilization of triptan users who receive drug prophylaxis for migraine versus triptan users who do not receive drug prophylaxis

OBJECTIVES: The objectives were 2-fold: (1) to describe the utilization patterns of new users of triptan therapy and (2) to measure the direct (pharmacy and medical) costs of migraine-related health care services in moderate-to-severe migraine patients treated with drug prophylaxis compared with migraine patients who are not treated with drug prophylaxis. METHODS: A retrospective administrative database study was conducted from the perspective of a managed care health plan. Patients initiating triptan therapy were identified, and utilization in the 12 months following initiation of drug therapy was determined. In addition, moderate-to-severe migraine patients were identified based on the quantity of triptan medication dispensed. Patients were classified as utilizing or not utilizing migraine prophylaxis. Migraine-specific health services costs in the 12 months following identification were determined. A multivariate ordinary least squares regression model was constructed to determine the impact of the use of drug prophylaxis on total cost. Utilizing the model, the difference in health services costs was predicted for each subject and the average treatment effect was computed. RESULTS: Thirty-nine percent of new triptan users received only 1 triptan claim during the 12-month follow-up period, accounting for 11.5% of the total triptan cost incurred by the health plan for this cohort. For new triptan users, triptan use in the first or second quarter was correlated with triptan use in the entire 12-month follow-up period (r = 0.187 and 0.279, respectively). The mean migrainerelated pharmacy cost per patient during the follow-up was $871; however, continuous users had mean costs ($1,505) nearly 3 times the mean costs for new users ($506, P<0.05). The average treatment effect of drug prophylaxis in moderate-to-severe migraine patients was a decrease of $560 ($514-$607) per patient per year in 1998-2001 dollars. CONCLUSION: High utilizers of migraine therapy can be identified early in treatment. Drug prophylaxis for migraine is cost saving, and an intervention program that increases the use of migraine prophylaxis in potential candidates could be cost beneficial.     

Introduction of pharmaceutical expertise in a palliative care team in Sweden

Objective This paper presents for the first time the inclusion of dispensing pharmacists, a special group of pharmacy professionals, in a Swedish palliative care team. It also presents the drug stock management in the medication room of the clinical area and the improvement of drug logistics. In addition to a dispensing pharmacist, a pharmacist was included in this part of the project as well. Setting The palliative care team at ASIH L?ngbro Park, Sweden. Method The intervention with the dispensing pharmacists as new members of the interdisciplinary palliative team was evaluated by a questionnaire to the staff. An inventory of the different drugs in stock was performed in March 2006 and in April 2007, respectively. The inventory turnover rate was determined and the drug consumption for the last 6 months of 2005 and 2006, respectively, was also analysed. Main outcome measures The questionnaire used rating scales allowing participants to rate the questions/statements. The number of different drugs and drug packages in stock were recorded during the inventories. Drug costs were calculated and the inventory turnover rate was determined by dividing the annual cost of drugs by the value of the inventory. Drug consumption was analysed using the Xplain statistical programme, a statistical tool from Apoteket AB. Results The overall impression of the dispensing pharmacists was positive. The staff reported advantages in having a dispensing pharmacist present at ASIH not only for the drug logistics, but also for drug-related queries. The inventory of the drug stock and the drug-handling process resulted in a 14% reduction of product numbers and a 36% reduction in the tied-up capital for drugs in stock. The inventory turnover rate increased from 6.7 to 9.5. A 7% reduction of medication costs was also observed when comparing the last 6 months of 2006 with the costs in 2005. Conclusion The principal result of this project is that inclusion of pharmaceutical expertise on a palliative care team can be a valuable asset for the team in pharmaceutical issues and of great benefit for stock management, including cost savings and improvement of drug logistics.