HOSPITAL PHARMACY ASSIGNMENT

SUBMITTED TO:
DR ZUBAIR MALIK SAB
SUBMITTED BY:
ANSAR MUSHTAQ (20)
TOPIC OF ASSIGNMENT:
Role of the pharmacist in reducing healthcare costs

COLLEGE OF PHARMACY, UNIVERSITY OF

SARGODHA
Role of the pharmacist in reducing
healthcare costs

Introduction
The role of the pharmacist has evolved substantially in recent decades. The traditional
activities of the profession primarily focused on the dispensing and supply of
medications, while interaction with other healthcare professionals was somewhat
limited. Nowadays, pharmacists also ensure the rational and cost-effective use of
medicines, promote healthy living, and improve clinical outcomes by actively engaging
in direct patient care and collaborating with many healthcare disciplines. With this
expanding scope of practice, pharmacists are being recognized as key components in
providing individualized patient care as part of interprofessional healthcare teams.

Escalating healthcare costs

Healthcare costs are rising worldwide, due to the combination of an aging population,
technological advances, the prevalence of medication errors, and increased spending on
medicines year on year. 1) As the global population ages, healthcare organizations are
challenged with the increasing burden of chronic diseases and polypharmacy among
older adults.2) The increased number of medicines being consumed by the elderly, as
well as the rising cost of newer pharmacotherapies, has intensified the pressure on
healthcare organizations to identify and implement cost-control measures. Pharmacists
have a major role in lowering costs by critically reviewing the pharmacotherapy of
multimorbid elderly patients. The reduction of inappropriately prescribed medicines not
only produces savings in the cost of each individual medicine but also reduces the risk
of adverse drug events (ADEs) that often contribute to prolonged and expensive
hospital admissions.
Under constrained financial conditions, healthcare services need to demonstrate that
they remain cost-effective, given the investment in their provision. Numerous
publications describe the diversifying role of pharmacists in a variety of practice
settings, and these are not just limited to developed countries. Previous review articles
have shown positive economic outcomes associated with pharmacist interventions and
clinical pharmacy services. However, despite these developments, this has not
diminished the need to prove continually the economic benefit of such services, as
some of the papers included in these review articles did not include full economic
evaluations.

Pharmacoeconomics, cost savings, and cost avoidance

The continuing high cost of medicines emphasizes the increasing importance of

pharmacoeconomic evaluation studies. These studies allow us to identify, measure, and
compare the cost of different pharmacotherapies or services and what significance they
will have on healthcare budgets and patient health. In this field, pharmacists can have
a major influence on healthcare decision makers with regard to better allocation of
resources and expenditure, so as to optimize population health from the use of
medicines. With their unique knowledge of medicines, pharmacists are central figures in
decreasing healthcare expenditure through cost savings on medicines and cost
avoidance. Cost savings allude to reductions in current spending due to changes in the
expense on a patient’s treatment, e.g., switching from intravenous to oral therapy
where appropriate. In contrast, cost avoidance refers to an intervention that reduces
potential future spending that may have occurred without the intervention. An example
of this would be a pharmacist suggesting the discontinuation of a potentially
inappropriate medicine in an elderly patient which could result in a future ADE, hence
reducing the potential cost of a general practitioner (GP) referral or hospital admission,
as well as eliminating the actual cost of the medicine. Over an extended period of time,
limiting costs through cost avoidance measures can result in significant cost savings.

Medication errors, inappropriate prescribing, and ADEs

Medication errors and inappropriate prescribing are recognized as major problems, both
clinically and economically, for the healthcare system. They can contribute to adverse
drug reactions (ADRs) and ADEs, especially in elderly patients, and can have a major
impact on patient morbidity and mortality. ADEs can result in increased healthcare
utilization, as well as extend hospital admissions, hence incurring further medical
costs. One large study demonstrated that ADRs were responsible for 6.5% of hospital
admissions, while a recent meta-analysis showed that ADEs may occur in 16.88% of
patients during hospitalization. Patients affected by an ADE have their hospital
admission prolonged by an average of 2 days, at an additional expense of ~US$2,000–
$2,500. Medication errors are very costly to healthcare systems, but a large portion of
these are preventable. Pharmacists have demonstrated a positive effect in preventing
medication errors and limiting inappropriate prescribing, thus reducing healthcare costs
by preventing hospital admission or reducing hospital length of stay (LOS).

Materials and methods

A comprehensive electronic literature search was conducted using the following
databases from inception up to and including November 2016: PubMed, Medline (Ovid),
CINAHL, Science Direct, and Google Scholar. Key search terms included but were not
limited to: “pharmacist” AND “cost” AND “economic evaluation” AND “hospital” AND
“community pharmacy”, as well as various synonyms or combinations of these terms.
Other search methods included citation searching and scanning reference lists of highly
cited key papers.

Chronic disease management

Chronic diseases are the leading cause of death and disability worldwide, and their
management accounts for more than two-thirds of global healthcare expenditure.
Pharmacists have the potential to play a greater role in the management of chronic
illnesses and make considerable savings in healthcare costs. As frontline healthcare
professionals, community pharmacists are in contact with this patient cohort regularly,
are specially trained to reduce disease severity, monitor medication therapy to achieve
desired clinical effects, reduce adverse health events, and can make recommendations
to patients or prescribers regarding pharmacotherapy where appropriate. Studies have
shown that pharmacists in primary care have the skills to manage patients with long-
term conditions, and this can result in both clinical and cost benefits for a variety of
chronic illnesses, such as
a) Cardiovascular disease
b) chronic obstructive
 c) pulmonary disease
d) diabetes
in the management of hypertension, pharmacists have been shown to improve patient
outcomes and represent a cost-effective alternative in comparison to those managed by
physicians.

Adherence
Medication adherence may be defined as “the extent to which patients take medications
as prescribed by their healthcare providers”. Even though good medication adherence
correlates with positive health outcomes, it is estimated that between 20% and 50% of
patients in developed countries may be nonadherent with their medications. No
adherence is associated with potential disease progression, pharmacotherapeutic
failure, and hospitalization. A study from the US found that 33%–69% of medication-
related hospital admissions may be due to poor medication adherence.

Medication nonadherence is an economic burden worldwide, and it is estimated that the

annual cost of nonadherence is $100 billion in the US alone

Medicines use review

It is important to highlight that patients’ use of medicines should be reviewed for
appropriateness before adherence is encouraged. This is particularly the case with
elderly patients, who may be on multiple medicines, where adherence may have
adverse consequences. A medicines use review (MUR) involves a private discussion
between a pharmacist and a patient, whereby the goal is to improve the patient’s
knowledge, adherence, and use of medicines. MURs also provide an opportunity for a
pharmacist to review a patient’s pharmacotherapy, including both prescribed and over-
the-counter (OTC) medicines. With an aging multimorbid population worldwide,
polypharmacy will continue to be a serious issue, and hence MURs by community
pharmacists will be significant in order to curb healthcare costs. Even though robust
research evidence is lacking with regard to the clinical and cost-effectiveness of MURs,
a recent article found that their value is now largely accepted, and that the benefit of
these MURs outweighs any costs that they may incur.

Management of minor ailments

According to a recent report in the UK, 5% and 13% of presentations to EDs and GPs,
respectively, represent minor ailments that could be managed in community
pharmacies. In this way, community pharmacists can play an important role in reducing
the clinical and economic burden of minor ailment consultations on other higher cost
areas of the health service. Pharmacists are specially trained in managing these self-
limiting conditions and deal with them daily as part of their normal practice, such as
colds and flu, hay fever, and various aches and pains. Pharmacists can provide first aid
to patients free of charge in the management of minor injuries to help avoid or reduce
potentially costly trips to the ED. Community pharmacists are available at convenient
hours and usually require no appointment, helping to keep minor ailments out of the GP
setting but also ensuring that patients with potentially serious illnesses are filtered
through to their GP
The cost benefits of minor ailment schemes are clear. Patients consulting more costly
branches of the healthcare system for minor ailments that could have been dealt with in
a community pharmacy is a waste of resources, patients’ time, and GPs’ time. Studies
have shown that community pharmacists’ management of minor ailments, as well as
the patients’ health-related outcomes, is equivalent to those seen in higher cost
settings. Additional economic evaluations will be required to highlight the continuing
cost benefits that these schemes can achieve.

Hospital pharmacists
Hospital pharmacists have had a major influence on the advancement of pharmacy
practice in recent decades. In many countries, hospital pharmacists have expanded
their roles beyond the dispensary, and now routinely provide clinical pharmacy services
at ward level, which includes reviewing patients’ medications and advising other
healthcare professionals with regard to pharmacotherapy. However, in several regions
worldwide, the evolution of hospital-pharmacy practice is not happening quickly
enough. In these areas, particularly in some parts of Africa and Asia, hospital
pharmacists have been predominantly limited to dispensary-based roles, meaning that
their expertise in medicine management is being underutilized.
Hospital pharmacists’ clinical activities often include medicines reconciliation at
transition points of care, medication management reviews for inpatients, provision of
medicines information to other healthcare professionals, selection of drug therapy,
monitoring patients for an appropriate therapeutic response to medicines, identifying
and reporting ADRs, patient counseling, as well as other duties to ensure the safe and
effective use of medicines in this setting. Pharmacist interventions are a key component
to a hospital pharmacist’s role in preventing medication-related problems (MRPs) and
have been defined as “any action by a clinical pharmacist that directly results in a
change in patient management or therapy”. Evidence from the literature is quite mixed
with regard to the cost-effectiveness of pharmacists’ interventions and related
measures, such as health outcomes and quality of life. However, many studies have
proven that pharmacist interventions have a positive impact on hospital budgets, but it
is difficult to elucidate which interventions were the most cost-effective

Inpatient medication review

Hospital admission appears to be an opportune time at which a pharmacist can
comprehensively review a patient’s pharmacotherapy; this is especially of value where
the hospitalization may have been drug-related or in patients with complex medication
regimens, such as the multimorbid elderly receiving polypharmacy. Medication reviews
allow hospital pharmacists to identify any MRPs and formulate their recommendations
to resolve these issues with their fellow healthcare professionals. MRPs can be very
costly to healthcare providers, as they can result in hospitalization, as well as increased
LOS and cost of stay.

Ward rounds
Traditionally, hospital pharmacists have provided their clinical services to wards by
carrying out daily ward visits, where they address any MRPs identified with appropriate
interventions. The pharmacist’s role in prescribing is usually retrospective, where there
may be long delays between the time of prescription and the pharmacist’s intervention,
increasing the risk for costly ADEs. Therefore, it may be more advantageous for a
pharmacist to be present at the time of prescribing, providing their specialized
knowledge when it may be needed most

Chemotherapy services
The rise in cancer incidence worldwide has resulted in an increased number of
prescriptions for antineoplastic agents. Chemotherapy regimens may be highly complex
and are more susceptible to error, as they necessitate frequent dosage adjustments.
Medication errors involving these regimens may be catastrophic due to the drugs’
narrow therapeutic index, and thus pharmacist involvement is crucial. One study
showed that even though the overall pharmacist intervention rate was low (1.59%),
just over 50% of these interventions were considered to be higher than clinically
“significant”, including 11% of cases being “very significant” or “extremely significant”,
producing an annual net cost benefit of $116,493. This highlights that the presence of a
pharmacist in a chemotherapy preparation unit can prevent ADEs in a high-risk
environment and result in a noteworthy positive effect on hospital budgets..

References
 Hughes DA. From NCE to NICE: the role of pharmacoeconomics. Br J Clin Pharmacol. 2010;

70(3):317–319.
 Hughes DA. An agenda for UK clinical pharmacology: pharmacoeconomics. Br J Clin
Pharmacol. 2012; 73(6):968–972.
 Papadopoulos J, Rebuck J, Lober C, et al. The critical care pharmacist: an essential intensive
care practitioner. Pharmacotherapy. 2002;22(11):1484–1488.