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A lab-pharmacy push to cut drug therapy costs.

Susceptibility and minimum inhibitory concentration are two essential guideposts for clinicians in their selection of proper antibiotic therapy. The lab and pharmacy in our 212-bed hospital have added a third--cost effectiveness.

We furnish relative cost data for different drugs clinicians may prescribe. This information, indicating how many times more expensive one drug is than another, accompanies each report of culture susceptibilities and minimum inhibitory concentrations. Clinicians also can look up the exact dollar cost of planned antibiotic therapy on charts widely posted throughout the hospital.

Some costly drugs have virtually disappeared from use as a result. Of course, our clinicians first had to be shown that cheaper antibiotics were just as effective.

As recently as six years ago, when I completed my medical technology training, the listing of antibiotics available for clinical use was relatively simple. I had learned drugs of choice for specific infections, and setting up gram negative and gram positive batteries for susceptibility testing did not require lengthy consideration.

Since then, new antibiotics have cascaded like Niagara Falls into the marketplace. Each of these many products promises a great deal. Pharmaceutical companies tell physicians about clinical effectiveness, indications and contraindications, possible adverse reactions, and methods of administration and dosage. But the companies and detail persons gloss over one critical point--R&d and other factors continually build up the prices of new drugs, threatening higher costs to patients in a period of already skyrocketing medical expenses.

Located in an area where many senior citizens live, our hospital has a large percentage of Medicare admissions. The transition to prospective payment makes it imperative that antibiotic therapy accomplish its purpose and be cost-effective at the same time. To prescribe wisely, clinicians need cost data as well as the other information about drugs.

An opportunity to present such data on an ongoing basis came in February 1983. The laboratory acquired an automated instrument that performed bacterial identification and four-hour susceptibility testing. We had to develop a new report form, and that was the vehicle the laboratory and pharmacy had been waiting for.

The clinical pharmacist devised a cost code based on the contract prices of each drug we carried (Figure I). The code is relative, assigning a "1" to the least expensive antibiotic and multiples of its cost to more expensive drugs. For example, treatment with oral ampicillin is listed as 1, while piperacillin is marked 52. That means piperacillin is 52 times more expensive to use than oral ampicillin.

As chief microbiologist, 1 designed a report form that would incorporate the cost code with susceptibility and MIC data. By May, the form had been approved by the infection control committee, presented to the medical staff, printed, and put into use.

Clinicians noticed the new information on the form and commented on it, but did not follow through as we had hoped. Since the code was relative, they did not perceive the actual dollar impact of switching to lower cost drugs. Clearly, something more was needed to get the message across.

The pharmacist next drew up a chart of comparative hospital costs for 10 days of intravenous therapy with equivalent doses of commonly used antibiotics. Copies in a hard-to-miss 14 X 8-1/2-inch size were posted in the doctors' lounges and all the dictating booths in medical and surgical units. The sample in Figure II displays costs for classes of drugs, but the chart that clinicians referred to had the names of the antibiotics.

The span of treatment costs was predictably wide. Penicillins ranged from a low of $24 for 10 days of I.V. therapy to a high of $568, for example.

Now a number of clinicians began prescribing with both susceptibilities and cost-effectiveness in mind. Others remained skeptical, however. A typical comment from the holdouts: "Gentamicin may in fact be cheaper, but more organisms are susceptible to tobramycin."

So, to make our case airtight, we distributed one final set of figures--susceptibility percentages for our institution (Figure III). These proved that lower-cost antibiotics were often at least as effective as much more expensive drugs, and even when they weren't, the difference was not significant.

Grop D Streptococcus, for example, is 96.2 per cent susceptible to a new broad spectrum penicillin and 92.5 per cent susceptible to an older form of penicillin. But 10-day I.V. therapy with the borad spectrum penicillin carries the $568 cost that we noted above, while comparable treatment with the other penicillin costs only $24. Among the aminoglycosides, one drug registered slightly higher susceptibility percentages among some organisms than products costing six and 12 times as much.

The joint laboratory-pharmacy cost awareness program has taken hold, although optimum drug prescribing is still a goal rather than a reality. One particularly encouraging set of statistics involves use of a costly third-generation cephalosporin. In May 1983, our hospital's clinicians ordered more than 1,300 doses of this antibiotics; in May 1984, they ordered none. It is still prescribed for patients from time to time, but not very often.

Other efforts to improve prescribing include discussions with individual clinicians and periodic reviews at medical staff meetings. We haven't felt a need to monitor physicians' ordering habits.

Pharmaceutical companies know about our program. This may be leading to more careful sales presentations at our hospital.

In summary, our laboratory-pharmacy partnership fulfills a responsibility for helping the clinician prescribe cost-effective and first-rate therapy. It's one small facet of the hospitalwide cooperation made more necessary than ever by prospective payment.
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Author:Rydzewski, M. Marcia
Publication:Medical Laboratory Observer
Date:Oct 1, 1984
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