Hospital charges for antibiotics

Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line

Background

Though antimicrobial stewardship programs (ASPs) are in place for patient safety, financial justification is often required. In 2016, the Infectious Diseases Society of America (IDSA) recommended that anti-infective costs be measured by patient-level administration data normalized for patient census. Few publications use this methodology. Here, we aim to compare 3 methods of drug cost analysis during 3 phases of an ASP as an example of this recommendation's implementation.

Methods

At a freestanding pediatric hospital, we retrospectively assessed anti-infective cost using pharmacy purchasing data, patient-level administration data from the electronic medical record (EMR), and patient-level administration data from the Pediatric Hospital Information Systems (PHIS) database, all normalized to patient census. Costs pre-ASP, while planning the ASP, and post-ASP were then compared for each method.

Results

Significant differences in costs between the methods were observed. Pharmacy purchasing endorsed minimal financial benefit (decrease planning to post-ASP of $590 dollars per 1000 patient-days), while the EMR and PHIS data endorsed a decrease of $12785 and $21380 per 1000 patient-days, respectively, for a total yearly cost savings of $54656 for pharmacy purchasing data, $1184336 for EMR data, and $2117522 for PHIS data.

Conclusions

Pharmacy purchasing data underestimated cost savings compared with EMR and PHIS data, while EMR and PHIS data were comparable in magnitude of savings. At Children's Hospital Colorado, savings justified the full cost of the ASP. EMR patient-level administration data, normalized to patient census, offers a readily available and standardized measure of anti-infective costs over time.

A multidisciplinary hospital-based antimicrobial use program: Impact on hospital pharmacy expenditures and drug use

The authors' hospital embarked on a three-component, multidisciplinary, hospital-based antimicrobial use program to cut costs and reduce inappropriate antimicrobial use. Initially, antimicrobial use patterns and costs were monitored for 12 months. For the next two years, an antimicrobial use program was implemented consisting of three strategies: automatic therapeutic interchanges; antimicrobial restriction policies; and parenteral to oral conversion. The program resulted in a reduction in the antimicrobial portion of the total pharmacy drug budget from 41.6% to 28.2%. Simultaneously, the average cost per dose per patient day dropped from $11.88 in 1991 to $10.16 in 1994. Overall, mean monthly acquisition cost savings rose from $6,810 in 1992 to $27,590 in 1994. This study demonstrates that a multidisciplinary antimicrobial use program in a Canadian hospital can effect dramatic cost savings and serve as a quality assurance activity of physician antimicrobial prescribing behaviour.

Antibiotic selection in obstetric patients

Penicillin and ampicillin are valuable antibiotics in obstetrics because of their excellent activity against group A and group B streptococci. In addition, ampicillin is the treatment of choice for enterococcal infections, particularly urinary tract infections. Limited spectrum cephalosporins are of primary value as prophylactic agents. Ceftriaxone, an intermediate spectrum agent, is an excellent drug for treatment of infections caused by N. gonorrhoeae. Extended spectrum cephalosporins, penicillins, and carbapenems provide sufficient coverage against pathogenic organisms to be used as single agents for treatment of polymicrobial infections such as chorioamnionitis and puerperal endometritis. Alternatively, combination regimens such as clindamycin or metronidazole plus an aminoglycoside or aztreonam are also highly effective in this clinical situation. Erythromycin and azithromycin have value primarily for treatment of endocervical chlamydial infections and mycoplasma pneumonia in obstetric patients and for intrapartum prophylaxis against group B streptococcal infection in patients who are allergic to beta-lactam antibiotics.

Guidance for clinicians in discerning and comparing the price of pharmaceutical agents

Discerning the price of a pharmaceutical agent is not as straightforward an exercise as might be imagined. The widely used average wholesale price is a misnamed figure that does not provide a consistent approximation of the cost of a drug at either the retail or hospital levels. While clinicians should consider the prices of medications when deciding on the agent to prescribe for both ethical and economic reasons, there is currently no comprehensive source of accurate drug prices. Unless and until such information is made available, prescribers are encouraged to consult dispensing pharmacists to learn of these costs.

Cost of gentamicin assays carried out by microbiology laboratories

AIMS

To assess the current range of prices charged for gentamicin assays in United Kingdom laboratories; and to examine the laboratories' likely response to increases or decreases in the demand for the service.

METHODS

A postal survey of the 420 members of the Association of Medical Microbiologists was used to establish the range of prices charged for aminoglycoside assays. Additionally, eight private institutions were contacted to determine what the private sector was charging for aminoglycoside assays. Reagent costs in the NHS laboratories were calculated by dividing the total cost of all aminoglycoside assay kits by the number of samples analysed.

RESULTS

The NHS and the private institutions both showed a wide price variation. Prices charged to an in-hospital requester for a peak and trough assay ranged from 5.00 pounds to 68.20 pounds (n = 44), and to an external private hospital, under a bulk service contract, from 5.00 pounds to 96.00 pounds (n = 47). Prices charged by private laboratories ranged from 49.00 pounds to 84.00 pounds (n = 8). There was a log linear correlation in the NHS laboratories between the reagent costs per assay and the number of assays performed per year, and most laboratories thought that their price per assay would be sensitive to increases or decreases in demand. Laboratories which had purchased their assay machines had lower reagent costs per assay but higher repair and maintenance costs. Overall, number of assays performed and method of payment for assay machinery only accounted for 44.8% of the observed variation in assay kit costs.

CONCLUSIONS

The price range for gentamicin assays in the United Kingdom is wide and is only partially explained by the number of assays performed. Most laboratories believe that they would experience a reduction in unit cost as output increases. The currently offered range of prices is, in part, due to variation in the laboratories' approach to costing the service provided and some laboratories charge prices which do not even cover the cost of assay kits. Overall, we believe that prices charged should be as close as possible to the marginal cost of the tests performed.

Cost effectiveness of once-daily oral antimicrobial therapy

Once daily dosing of oral antimicrobials achieves significantly better patient compliance than three or four times daily dosing, and limited data suggest that this is associated with greater efficacy. Comparison of once daily and twice daily dosing is less consistent, and most studies show only marginally better compliance with once daily dosing versus twice daily dosing. Detection of urinary antimicrobial activity provides a simple method for checking compliance with oral antimicrobials and deserves wider study. Counts of residual tablets have been shown to overestimate compliance. Intravenous formulations are always more expensive than equivalent oral formulations, and preparation and administration of intravenous drugs adds significant additional costs. Moreover, intravenous regimens are complex, and a number of studies have shown that serious errors occur in both preparation and administration of intravenous drugs. There is increasing evidence that serious infections can be adequately treated with oral drugs, and the excellent bioavailability of quinolones makes them particularly attractive for these indications. Clinicians require a method for checking absorption by patients with severe infection, and the Serum Bactericidal Test may provide a practical method for monitoring a wide variety of drugs.

Evaluating the cost-effectiveness of treatment with third-generation cephalosporins

Spreadsheet computer software was used to compare the estimated global treatment costs of the third-generation cephalosporins, cefotaxime and ceftriaxone, in the management of pneumonia using treatment schedules taken from current studies. Included in the analysis were not only acquisition costs, but also costs that contribute to total expenses for a course of treatment, such as those of (a) preparation and administration (disposable supplies, nursing, and pharmacy time), (b) projected laboratory costs to monitor for hypoprothrombinemia, and (c) complication costs (diarrhea, superinfection, pseudocholelithiasis, and so on). The cost analysis was performed using United States trial-derived factors. Where published cost factors were not available, reasonable estimates were sought. Our analysis indicates that cefotaxime therapy may be less costly than ceftriaxone therapy in the dosage schedules used in these clinical studies and routine clinical practice.

The nonvalue of retrospective peer comparison feedback in containing hospital antibiotic costs

Antibiotics have accounted for an increasing percentage of hospital pharmacy charges. Recently, an inexpensive method, automated peer comparison feedback, has been developed to influence physician use of resources. The documented success of several implementations of this strategy led to a one-year experiment to influence hospital antibiotic utilization. Each month, attending physicians in the top 50 percentiles for expenditure were notified of their status in relation to their peers. Expenditures by feedback and control groups were compared to determine whether feedback would result in reduced expenditures by individuals, or whether there would be a generalized reduction in expenditure by the entire group (Hawthorne effect). Over the year, no significant reduction in expenditure was noted. However, some important utilization patterns were identified. Although more surgical patients received antibiotics than did nonsurgical patients, surgical antibiotic costs were less. Surgical therapy was typically of shorter duration and involved the use of less expensive antibiotics. Multiple-antibiotic prescribing was less frequent on surgical services. Thirty percent of attending physicians were responsible for 80 percent of all antibiotic costs; 60 percent of those in this top group were members of the medical cohort.

IN CONCLUSION

(1) As implemented in the current study, automated peer comparison feedback was not an effective method for reducing antibiotic utilization; (2) Differences in prescribing patterns between services may dictate the best strategies for improving antibiotic utilization; (3) More attention should be directed toward the relatively small "reference group" of physicians responsible for most hospital antibiotic prescribing.