Transcript Additional Cost of High Risk Group in Actual Practice

COST IMPACT OF USING SPECIFIC CYCLOOXYGENASE II INHIBITORS IN ORTHOPEDIC OUTPATIENTS AT
LERDSIN HOSPITAL
Jitsuda Phosri M.Sc. in Pharm., Assist. Prof. Vithaya Kulsomboon Ph.D. , and Assist. Prof. Niyada Kiatying-Angsulee Ph.D.
International Graduate Program in Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
Abstract
Introduction
Problem Statement: The inappropriate prescribing of specific COX II inhibitors (C2I) has
economic impact on individual patient’s and overall health care cost.
Specific Cyclo-Oxygenase II (COX II)
Inhibitors, have been introduced in several
countries for the relief of chronic pain in
rheumatoid
arthritis
and
osteoarthritis.
Celecoxib and rofecoxib are members of these
specific COX II inhibitors, the incidence of
gastric side effects with this new group is lower
than observed in earlier NSAIDs.
Objectives: To characterize the patterns of C2I use and to determine it’s cost impact in
patients who were at low risk and high risk for gastrointestinal adverse effects.
Designs: Retrospective design
Settings: Lerdsin Hospital, the Institute of Orthopedics of Ministry of Public Health,
Bangkok, Thailand.
Study Population: Data from orthopedic outpatients having C2I and NSAIDs during
November to December 2002 were collected. The proportionate sample was selected based on
the two months drug utilization data including 519 prescriptions of C2I and 594 prescriptions of
NSAIDs. To select the prescriptions, computerized simple random sampling was used. The
National Institute for Clinical Excellence of United Kingdom Guidance for C2I use was
employed to determine whether the patients receiving C2I were at high risk of GI adverse
events.
Outcome Measures: Total cost per prescription, average cost per prescription, average cost
per day, mean duration of prescribed drug, and cost waste of C2I versus NSAIDs use in low risk
group of actual practice and standard treatment. Additional cost of NSAIDs compared with C2I
in high risk group of actual practice.
Results: Two hundred and eight (40.1%) patients receiving C2I and 113 (19.0%) patients
receiving NSAIDs were considered to be at high risk for upper GI adverse effects. Of the
patients receiving prescriptions for C2I, 112 (21.6%) received C2I alone and 159 (30.6%)
received Gastro-Protective Agents (GPA) in addition to C2I. The results showed that
prescribing of C2I compared with NSAIDs among patients who were not at high risk of GI
adverse events resulted in excessive expenditure of 2.4 million Baht/year. Compared with the
three highest consumption drugs in the hospital including diclofenac, Voltaren®, and ibuprofen
400 mg, cost waste of C2I use were 3.4, 1.7 or 3.2 million Baht/year, respectively. The
additional cost of NSAIDs compared with celecoxib or rofecoxib use in the high risk group,
practice, were 1.5 or 1.8 million Baht/year, respectively.
Conclusions: The cost impact of C2I use among patients who were at low risk for
gastrointestinal adverse events compared with NSAIDs at Lerdsin Hospital was 2.4 million
Baht/year. Because of the high cost impact of C2I use, it is necessary to employ clinical practice
guideline for prescribing restriction and prospective drug use review for C2I.
Funding Sources: Graduate Program in Social and Administrative Pharmacy and Graduate
School of Chulalongkorn University
Methods
Objectives
To characterize the patterns of use of specific
COX II inhibitors in orthopedic outpatients at
Lerdsin Hospital.
Research Design
A retrospective Study during November
2002 to December 2002 in orthopedic
outpatient clinic at Lerdsin Hospital, the
Institute of Orthopedics of Ministry of
Public Health, Bangkok, Thailand
To determine cost impact of using specific
COX II inhibitors in orthopedic outpatients who
are in low risk and high risk GI adverse effects.
Subjects & Instrument
In Thailand, there had been an increasing
trend of specific COX II inhibitors utilization;
expenditures on celecoxib dramatically
increased from 45.1 million Baht in 1999 to
295.6
million
Baht
while
rofecoxib
expenditures slightly increased from 20.1
million Baht in 1999 to 155.8 million Baht in
2001.
Data
from
orthopedic
outpatient
prescriptions and OPD Card that having
specific COX II inhibitors and NSAIDs was
collected,
including,
patients’
characteristics, patients’ histories and
physicians prescribing.
Data collection form was used to be
instrument of this study.
The inappropriate prescribing of specific
COX II inhibitors (COX II) has economic
impact on individual patient’s and overall
health care cost.
SPSS was used for analyzing the data.
Pattern of Drug Use
Figure 1: Pattern of Specific COX-II Inhibitors Use in Orthopedic
Outpatient Department at Lerdsin Hospital
Results
Patient Characteristics
Concerning age of patients, 35.1% of specific
COX II inhibitors group and 15.3% of NSAIDs
group were patients aged ≥ 65 years. From 2
test, there was an association between age and
patient receiving specific COX II inhibitors.
The result showed that, number of patients aged
≥ 65 years receiving specific COX II inhibitors
more than number of patients aged ≥ 65 years
receiving NSAIDs (P< 0.0001).
Based on our observation, it appeared that the
number of patient in CSMBS group received
specific COX II inhibitors was greater than the
number of patient who received NSAIDs. We
conducted Chi Square test (2) whether there
was an association between CSMBS and
patients receiving specific COX II inhibitors.
The results showed that, the number of patients
with CSMBS coverage receiving specific COX
II inhibitors were greater than the others
(P<0.0001).
COX-II +
Analgesic;40%
Table 3: Additional Cost of High Risk Group in Actual
Practice
Total Cost
(Baht)
Average Cost
957.89
936.66
per
prescription
(Baht)
Mean
31.17
27.24
Duration
(Days)
Average Cost
30.73
34.39
per Day
Baht)
Number of
81
127
Prescriptions
1,536,033.48 1,824,039.78
Additional
Cost
(Baht/year)
NSAIDs
Gr.
26,776.67
236.96
21.36
11.21
113
-
Cost Waste of Low Risk Group in Actual
Practice and Standard treatment
COX-II Alone
COX-II + NSAIDs Injection
+ Other
COX-II + Analgesic
COX-II + GPA
+ Other; 31%
COX-II +
NSAIDs
Injection+
Other; 3%
Study
Pattern of Drug Use in Low Risk and High Risk Group
Table 1: Number of Prescriptions in Low Risk and High Risk for
Upper GI Adverse Effects of Specific COX II Inhibitors and NSAIDs
Using during November 2002 to December 2002 of Orthopedic
Outpatients at Lerdsin Hospital.
Group
Celecoxib
Rofecoxib
NSAIDs
(N = 185)
(N = 334)
(N = 594)
No.of
Table 2:Cost Waste of Low Risk Group in Actual
Practice and Standard Treatment
COX-II + Balm
%
Prescriptions
No.of
%
Prescriptions
No.of
56.22
207
61.98
481
80.98
High Risk
81
43.78
127
38.02
113
19.02
185
100
334
100
594
100
Cost Waste
COX II compared with NSAIDs in low
risk for actual practice
2.4 million
Baht/year.
COX II compared with NSAIDs in low
risk for standard treatment e.g., Diclofenac
3.4 million Baht/year, Voltaren® 1.7 million
Baht/year and Ibuprofen 400 mg 3.2 million
Baht/year.
Additional Cost
NSAIDs compared with specific COX II
inhibitors in high risk for actual practice:
Celecoxib 1.5 million Baht/year, Rofecoxib
1.8 million Baht/year.
Standard Treatment
Specific COX II
Specific COX II Specific COX II Specific COX II
Inhibitors vs
Inhibitors vs
Inhibitors vs
Inhibitors vs
NSAIDs
Diclofenac
Voltaren®
Ibuprofen (400)
Sample
169,568.08
236,970.01
117,884.38
226,047.18
2 months
405,204.76
566,363.76
281,628.30
540,247.08
2,431,228.56
3,398,182.56
1,689,769.80
3,241,482.48
1 Year
Prescriptions
104
Pattern of Specific COX II Inhibitors Use
Physician prescribed appropriate COX II
use in high risk was 40.08% and
inappropriate COX II use in low risk group
was 59.92%
Actual Practice
%
Low Risk
Summary
Additional Cost of High Risk Group in
Actual Practice
Rofecoxib
Gr.
118,956.06
COX-II Alone;
22%
COX-II + GPA+ Other
Total
Celecoxib
Gr.
77,589.12
COX-II + Balm;
4%
Discussion
In this study, the most frequent prescribing
was specific COX II inhibitors plus GPA or
NSAIDs plus GPA. The results of this study
were different from a previous study conducted
by Phochanukul (1999), which demonstrated
that the most frequent prescribing pattern was
specific COX II inhibitors alone or NSAIDs
alone.
In Thailand, Pharmaceutical and Therapeutic
Committee (PTC) should develop and
implement prior authorization policy for
appropriate specific COX II inhibitors
utilization in the hospital. This policy would
help saving substantial amount of money in
long term.
Conclusion &
Policy Recommendation
Cost waste of specific COX II inhibitors in
low risk group compared with NSAIDs was 2.4
million Baht/year in actual practice.
Compared to Diclofenac, Voltaren and
Ibuprofen 400 mg, excessive expenditures were
3.4, 1.7, and 3.2 million Baht/year.
Further study should focus on individual
patient’s payment status to find our whether the
payment status is a factor influencing physician
prescribing.
Pharmaceutical and Therapeutic Committee
(PTC) should implement Drug Use Review
(DUR) to evaluate specific COX II inhibitors
use in clinical practice.
The Clinical Practice Guideline (CPG) of
specific COX II inhibitors should be reviewed
in order to restrict specific COX II inhibitors
use for high risk group only.