A multidisciplinary approach to hospital-based drug cost containment

Cost-Effective and Sustainable Drug Use in Hospitals: A Systematic and Practice-Based Approach

BACKGROUND AND OBJECTIVE

Rising healthcare costs challenge the financial sustainability of healthcare systems. Interventional pharmacoeconomics has emerged as a vital discipline to improve the cost-effective and sustainable use of drugs in clinical practice. However, current efforts are often fragmented, highlighting the need for an integrated hospital-wide approach. This study aimed to develop a scalable framework to systematically identify and implement cost-effective and sustainable drug use practices in hospitals.

METHODS

This study was conducted at the Erasmus University Medical Centre in Rotterdam between December 2022 and July 2023. A novel '8-Step Efficiency Model' was designed to systematically identify and evaluate strategies for cost-effective and sustainable drug use. The process involved identifying high-expenditure drugs, systematically assessing these drugs using the Efficiency Model, and conducting a multi-disciplinary evaluation of the proposed cost-effectiveness strategies.

RESULTS

The study assessed 39 high-cost drugs, representing 57% of the Dutch national expensive drug expenditure in 2021. Initiatives for enhancing cost-effectiveness and sustainability were identified or developed for 27 out of the 39 assessed drugs (51% of the national drug expenditure in 2021). Case examples of infliximab (e.g., wastage prevention) and intravenous immunoglobulins (e.g., lean body weight dosing) illustrate practical applications of the framework, resulting in substantial cost savings and improved sustainability.

CONCLUSIONS

This study presents a systematic scalable model for enhancing the cost-effectiveness of high-expenditure drugs in hospital settings. This approach not only addresses financial sustainability but also promotes the quality of patient care and sustainable drug use. This model could serve as a generic blueprint for other institutions to identify and implement cost-effective and sustainable drug use strategies.

Funds Reimbursement of High-Cost Drugs in Gastrointestinal Oncology: An Italian Real Practice 1 Year Experience at the National Cancer Institute of Naples

Introduction: The therapeutic scenario of Oncology is enriching of innovative agents which are determining an increase in public expenditure because of their high cost. In Italy, a web-based government Registry is used to monitor the clinical use of these drugs and, in later phases, to obtain funds reimbursement according to specific economic agreements with companies.

Methods: A health policy expert Pharmacist was included in the multidisciplinary team of the Department of Abdominal Oncology of the National Cancer Institute (NCI) of Naples “G. Pascale Foundation” in order to improve the management of the Registry for oncologic drugs monitoring. Pharmacist activities were: basal data registration, prescription appropriateness, drug request, response monitoring, toxicity reporting, follow-up, reimbursement request. These activities were conducted in strict interrelation with clinicians. The source of data were medical records and a web-based national reimbursement platform. The analysis of the economic impact of this strategy was descriptive and it was indicated as resources recovery comparing 2 years: 2015 vs. 2016. The currency reference used was the Euro (€).

Results: A total of 932 patients were followed-up and registered, 365 treatments are ongoing at the Department of Abdominal Oncology (NCI of Naples, Italy). The most prescribed biologic drug in advanced gastrointestinal cancers was bevacizumab. Compared to the year 2015, in 2016 we recorded a strong increase of reimbursements: EUR 881.712,42 vs. EUR 214.554,98.

Conclusions: We suggest that the reimbursement process can be improved when a health policy reimbursement professional Pharmacist is integrated in the multidisciplinary team along with clinicians.

Exploring the concept of a team approach to wound care: Managing wounds as a team

Background

The growing prevalence and incidence of nonhealing acute and chronic wounds is a worrying concern. A major challenge is the lack of united services aimed at addressing the complex needs of individuals with wounds. However, the WHO argues that interprofessional collaboration in education and practice is key to providing the best patient care, enhancing clinical and health-related outcomes and strengthening the health system. It is based on this background that the team approach to wound care project was conceptualised. The project was jointly initiated and realised by the Association for the Advancement of Wound Care (AAWC-USA), the Australian Wound Management Association (AWMA) and the European Wound Management Association (EWMA).

Aim

The aim of this project was to develop a universal model for the adoption of a team approach to wound care.

Objective

The overarching objective of this project was to provide recommendations for implementing a team approach to wound care within all clinical settings and through this to develop a model for advocating the team approach toward decision makers in national government levels.

Method

An integrative literature review was conducted. Using this knowledge, the authors arrived at a consensus on the most appropriate model to adopt and realise a team approach to wound care.

Results

Eighty four articles met the inclusion criteria. Following data extraction, it was evident that none of the articles provided a definition for the terms multidisciplinary, interdisciplinary or transdisciplinary in the context of wound care. Given this lack of clarity within the wound care literature, the authors have here developed a Universal Model for the Team Approach to Wound Care to fill this gap in our current understanding.

Conclusion

We advocate that the patient should be at the heart of all decision-making, as working with the Universal Model for the Team Approach to Wound Care begins with the needs of the patient. To facilitate this, we suggest use of a wound navigator who acts as an advocate for the patient. Overall, we feel that the guidance provided within this document serves to illuminate the importance of a team approach to wound care, in addition to providing a clear model on how to achieve such an approach to care. We look forward to gathering evidence of the impact of this model of care on clinical and financial outcomes and will continue to share updates over time.

Implementation of antibiotic management teams in Belgian hospitals

In 2002-03, the Belgian government subsidized in part the activities of local Antibiotic Managers (AMs) in 36 hospitals selected based on the presence of an operational multidisciplinary Antibiotic Management Team (AMT). AMs were trained as Internists (28), Microbiologists (13) and Hospital Pharmacists (13). The hospitals were representative of Belgian hospitals in affiliation, regional origin and size. The financing scheme allowed the implementation of 175 antibiotic management interventions, with a mean of 5 interventions/hospital. The activities reported in the first 9-month progress reports were analyzed according to national guidelines for AMTs. All hospitals irrespective of size or affiliation had undertaken a wide range of measures: review of formulary (29), implementation of new clinical guidelines (24), restricted access to selected antibiotics (25), improvement of antibiotic susceptibility testing methods (12), development of antibiotic consumption database (35) and analysis of antibacterial susceptibility data (31). Advertisement type categorization of communication methods showed that education of prescribers was based on multimodal communication. All hospitals used at least one passive method, 39% at least one active method and 55% at least one personalized method. The quality of communication was higher in hospitals with teaching affiliation. In conclusion, hospitals that received a financial incentive under theAMT pilot phase have developed multimodal antibiotic policy interventions independently of the hospital size and teaching status. Extension to all Belgian hospitals appears warranted. The impact of AMTs and AMs on the quality of use of antibiotics and trends of antibiotic resistance and cost will be monitored based on standardized indicators.

Bonnes pratiques de prescription des antibiotiques pour la prise en charge des infections urinaires en milieu hospitalier : identification des écarts aux recommandations et actions correctrices

OBJECTIVE

We analyzed the adequacy of antibiotic therapy prescribed for urinary tract infections (UTI): prostatitis, pyelonephritis, indwelling catheter-associated UTIs, or other undefined UTIs.

DESIGN

The adequacy of prescriptions to local guidelines was assessed retrospectively in two wards (Internal Medicine and Surgical Urology) of the Nantes University Hospital. The principal criteria involved simultaneously: choice of the molecule, dose, and treatment duration. Non-observances of guidelines were major (non-adequacy of the molecule, prescription of a non-active molecule according to in vitro susceptibility tests, non-appropriate treatment abstention), or minor (non-justified treatment, non-justified bitherapy, no prescription of bitherapy when requested, no treatment adaptation when requested, too short or too long treatment length, dosage mistakes).

RESULTS

One thousand eighty-six infections were collected over a 24-month period. The overall rate of adequate prescriptions was 40.1% (46.6% in Internal Medicine and 36.5% in Surgical Urology). In Internal Medicine (226 non observance among 389 prescriptions), the ratio of major non-observance of guidelines was 9.8%. Among them, 44.7% were non-appropriate treatment abstentions. In Surgical Urology (539 non observance out of 695 prescriptions), non-observance related to treatment length were the most frequent. The ratio of major non-observance was 19.9%. Among them, non-adequacy of the molecule reached 60.7%. Non-justified treatment and non-appropriate bitherapies were frequent.

CONCLUSIONS

For both units, indwelling catheter-related UTIs and other UTIs accounted for more than 50% of the infections although not detailed in the local guidelines. Identifying and analyzing Non observance may lead to targeted correcting actions to improve prescription quality.

Public drug procurement: the lessons from a drug tender in a teaching hospital of a transition country

INTRODUCTION

There are scarce descriptions of hospital drug procurement in the primary literature. The aim of this study was to analyse the drug tender led by a clinical pharmacologist in a 1200-bed university hospital in Serbia, a developing country in socio-economic transition, and to give recommendations for future steps in hospital drug policy.

PROCEDURE AND OUTCOMES

Drug tendering was conducted according to the public procurement law from January to April 2003. Analysis included the method of defined daily doses and anatomical therapeutic chemical classification, as well as minimal tender prices, free market prices, essential drugs and domestic and foreign manufacturers. The drug tender list consisted of 548 products, 1,315,501 pharmaceutical units and 312 drug entities, among which 164 were essential. For purchasing purposes, 479 drug formulations were selected, costing approximately 1.4 million Euros (approximately 10% of hospital budget). Three-quarters of the expenditure consisted of antimicrobials (29.1%), cytotoxics (28.8%) and intravenous infusions (17.7%). The top 20 drugs consumed 62.2% of the total drug expenditure. Competition for the most expensive and/or most used drugs was the key for financial success of applicants, even when they offered a limited number of drugs. The tender achieved 4.6% and 17.2% cost savings in comparison with minimal tender price and free-market price, respectively. The tender did not provide a fair balance between domestic and foreign manufacturers.

CONCLUSION

The drug tender is resource-consuming, laborious, and risky job. Aggregation of individual tenders, on a national level and/or regional ones, is probably the best choice for hospitals in transition countries at this time.

[The economic impact of inadequate prescriptions]

The impact of antibiotic therapy has gone to considerable expense. The review of literature demonstrates that an optimal use of economical resources can be achieved by an improvement of medical prescriptions. This improvement of prescriptions can be obtained for prophylaxy and for curative therapy. Cost savings can be as high as one-year budget for the recruitment of an infectious diseases consultant.