Cost Analysis of Capsule-versus-Tablet Dilution and Administration in Long-Term Care

I. Barton Frenchman Theodore Prince

Design: Time study in an idealized long-term care environment.

Setting: A 180-bed long-term care facility.

Subjects: Nurses who were experienced in preparing medication dilutions for residents with mild difficulties in swallowing but who were alert and oriented.

Interventions: Three antihypertensive medications were mixed in applesauce and administered to patients with mild swallowing difficulties. Medication carts were positioned at the patient's room, and no distractions were allowed to interfere with the dilution preparations by the nurse.

Main Outcome Measures: Total product acquisition and labor costs for preparation and administration of Capoten tablets, Altace capsules, and Vasotec tablets.

Results: Total monthly costs between three different medications were calculated based upon time studies, labor, and acquisition costs. Once-a-day dosing with capsules proved to be the least costly.

Conclusion: Capsules are more cost-effective than tablets for delivery in diluted form to patients in long-term care nursing facilities.

Key Words: Drug administration, Medication dilutions, Medication-preparation time, Swallowing, Oral solid dosage forms, Nurses, Costs.

Consult Pharm 1997; 12: 704-706.

In long-term care facilities, many residents suffer from dysphagia (difficulty in swallowing). For hypertensive and other patients, this can interfere with their ability to take medication as prescribed. To facilitate swallowing, nurses must crush or open solid oral dosage forms and mix the contents into applesauce or other/dilutents before administration. The chore of opening, breaking up, or crushing tablets can be tedious, time consuming, and costly.

Dysphagia has many causes but, in the elderly, it usually results from lumen narrowing, extrinsic compression of the esophagus, swallowing reflux lesions, weakness of the pharyngeal striated muscle, or esophageal smooth muscle disorders. Whatever the cause, the patient must be provided with an easy-to-swallow medication form for medically necessary therapy.

The total cost of drug therapy for nursing home residents must take into account the amount of time required for drug administration as a contributing factor.^1,2 Nurses spend much valuable time breaking up or crushing medications during a medication-administration "pass," and this takes away from time they could spend in direct patient care.

Medication acquisition costs are a major factor in formulary decisions. However, such decisions should be made based on a two-tier consideration for both facilitation of dosing and analysis of total (acquisition plus administration) costs.

To determine the time required in long-term care facilities to prepare solid oral dosage forms for administration to dysphagic patients, we conducted a study of three antihypertensive medications. To continue previous research,¹ we analyzed the total costs of medications that could be given once daily as well as those requiring multiple daily doses.

Methods

To determine the fixed costs of labor associated with the preparation of drug products for administration to dysphagic patients, we timed medication preparation for 15 different long-term care facility residents by three different nurses, for a total of 45 patient medication administrations. The study was conducted in a 180-bed long-term care facility during the day shift (seven a.m. to three p.m.).

We selected three antihypertensive medications for cost analysis: Capoten 25 mg t.i.d., Vasotec 5 mg b.i.d., and Altace 2.5 mg q.d. Capoten and Vasotec are available as tablets, while Altace is marketed as a capsule.

Timing for medication-administration pass after dilution with applesauce was created under an ideal situation. Only those residents who could swallow semisolid dosage forms and were considered alert and oriented were included. Distractions such as telephone, pagers, and call bells were removed during the pass. The medication cart was positioned near or at the patient's room. The timing of the task began when the nurse arrived at the medication cart and ended upon initialing of the medication-administration record.

The average medication-administration times were then calculated. The hourly wage of a nurse was calculated using the average of the hourly rates of per diem, agency, and salaried nurses at this facility. Costs of benefits were added to salaried nurses' rates. The labor cost associated with medication-administration was determined by multiplying the calculated hourly wage times the mean medication-administration time in hours.

Medication acquisition costs were obtained from the 1996 Redbook listing for average wholesale price. We compared the costs of 30 days' therapy with the usual maintenance listed above.

Results

We found that nurses required an average of 23 seconds to crush, dilute, and administer one dose using the tablet preparations (Capoten and Vasotec). Altace, being a capsule that could be emptied into the applesauce, required an average of 17 seconds per dose.

As shown in Table 1, the need for multiple daily administrations of Capoten and Vasotec further increased their total costs of therapy. With all factors considered, the total monthly cost of a once-daily medication in capsule form was $112.50 and $70.70 less than, respectively, three- and two-times daily antihypertensive agents.

Table 1. Time and Cost Comparisons of Three Antihypertensive Medications with Dilution for Dysphagic Patients

Variable	Capoten 25 mg t.i.d.	Vasotec 5 mg b.i.d.	Altace 2.5 mg q.d.
Cost per dosage form ($)	0.75	0.98	0.72
Daily cost of medication ($)	2.25	1.96	0.72
Cost of 30 days' medication ($)	67.50	58.80	21.60
Time to crush/dilute dosage form (sec)	23	23	17
Labor costs per month ($)a	85.50	57.00	28.50
Dilution costs per month ($)a	14.20	9.60	4.60
Total costs ($)	167.20	125.40	54.70

a Based on average hourly wage plus benefits of $25.00 for nurses.

Discussion

The use of pharmaceutically elegant dosage forms in the elderly population of long-term care facilities has long presented a challenge to consultant pharmacists and nurses alike. In this study, the cost impact of the need to dilute solid oral dosage forms in semisolid foods was assessed using direct observation of nurses.

To do so, we created an ideal environment in which nurses were not distracted by interruptions common in nursing homes. The patients involved were also alert, oriented, and cooperative. Both of these factors likely minimized the time needed for medication administration, therefore reducing the impact of cost differences we identified between the three drug products.

We observed three different nurses and timed them during administration of medications to 15 different patients. Since coordination and dexterity vary between nurses, the average of three times was incorporated into our cost formulas as representative of the actual time of administration for all nurses in this facility.

Conclusion

Our results indicate that, for medications that must be mixed with semisolid foods before administration, the use of drugs marketed in capsules that can be given once daily minimizes the time needed for medication administration in long-term care facility residents. As more medications become available in capsule or other easy-to-mix dosage forms, consultant pharmacists can use these results to estimate the impact of such innovations on medication costs and administration times.

Please submit manuscripts to William Stroemer, ASCP, 1321 Duke St., Alexandria, VA 22314; 703-739-1300.