Quantifying Potential Cost Savings of Pharmacists' Interventions in Short-Stay Patients

James A. Anderson Bisrat Hailemeskel

Design: A retrospective review of the DRR.

Setting: 30-bed step-down unit within the Methodist Medical Center of Illinois licensed as skilled-care beds but with subacute-care patients.

Patients: All patients admitted to the unit over a 24-month period who had a DRR completed at least once during their stay.

Interventions: Pharmacist's recommendations as part of the monthly DRR for calendar years 1994 and 1995. Recommendations were conveyed in writing and/or orally to the attending physician or charge nurse.

Main Outcome Measures: Cost savings (in 1993 dollars) based on pharmacy contributions to total patient care. Specific measures-percentage of interventions per patient, number and type of interventions, and impact of pharmacist recommendations-were quantified using the CliniTrend software program.

Results: Of the 553 patient charts reviewed, 770 interventions were made secondary to DRR. A predicted pharmacy drug cost savings of $7,972.73 was realized, for an overall patient savings of $20.04 per patient per DRR.

Conclusion: This study documented direct-cost savings in a step-down unit as a result of the consultant pharmacist's interventions. Further investigation is needed to determine cost savings over a more extended patient stay and in areas affected by DRR other than drug cost savings alone.

Key Words: Drug regimen review, Costs, Pharmacists, Interventions, Consultant pharmacists, Subacute care.

Abbreviations Used: DRR = Drug regimen review; LTCFs = Long-term care facilities.

Consult Pharm 1997; 12: 558-64.

Pharmacists' DRR activities are generally performed once each month in LTCFs. For patients with short lengths of stay-including patients in subacute-care units-this once-monthly review may be too infrequent for several reasons. First, many patients are already discharged before the pharmacist conducts the review, and many comments made by the pharmacist are not read by the physician before patient discharge. Further, the more acute nature of patients' conditions dictates more rapid intervention when problems are present.

In this research report, we analyze the cost impact of consultant pharmacists' DRR activities in a hospital-based step-down unit. While licensed as skilled-care beds, the type of patient most often present in the unit could be more accurately described a subacute care patients. Our objective was to quantify the impact of consultant pharmacists in a short-stay unit using traditional once-monthly DRR, with attention to any potential cost savings that would result from more frequent reviews.

Methods

Data for this retrospective study were collected as part of routine monthly DRR activities of the consultant pharmacist in the step-down unit of the Methodist Medical Center of Peoria. Pharmacists' interventions for these subacute-care patients covered the calendar years 1994 and 1995. During this period, the consultant pharmacist reviewed the drug regimens of 553 residents.

Pharmacist interventions were logged using CliniTrend, a computer software program developed by TASC, Inc. for the American Society of Health-System Pharmacists. The computer software program is used to analyze and quantify clinical services. Our goal is to systematically quantify data collection and analysis, and ultimately determine whether pharmacists' activities had a favorable effect on the total cost of patient care. Dollar values presented in this report reflect the original price defaults of the computer program. Allowing for modifications, we have applied the program to our study population and believe that it has served our purposes in quantifying time and cost benefits.

The study population consisted of those patients who had a DRR performed at least once while they were residents of our unit. Data collection spanned their entire admission (as the length of stay on this wing is so short) and encompassed all admissions during the 24-month period. Cost savings resulting from interventions were calculated using the computer program and published reports. Cost savings were not calculated for discontinued drugs (e.g., as-needed agents) not currently being administered.

Table 1 lists the frequency and types of interventions by the consultant pharmacist. We identified three areas of consideration associated with these costs. The first was actual cost reductions produced by a pharmacist's recommendation. An example is documentation of duplication of drugs for the same patient. In this case, the attending physician might discontinue one or more medications, thus directly decreasing drug costs.

Table 1. Occurrence and Type of Interventions by Consultant Pharmacists in a Hospital-Based Step-Down Unit

Type of intervention	Total No. (%)	(n = 770)
1. Duplication of drugs for same patient	15	(1.9)
2. Drugs administered in disregard of stop orders	2	(0.3)
3. Patients receiving three or more laxatives concurrently	3	(0.4)
4. Continuous use of hypnotics for > 30 days	1	(0.1)
5. Use of two or more hypnotics or use in excess of listed maximum dose	1	(0.1)
6. Use of anxiolytics in excess of listed maximum dose	2	(0.3)
7. Patients on antihypertensives without a blood pressure recorded weekly	11	(1.5)
8. Patients on anticoagulants with no monthly clotting tests	18	(2.3)
9. Patients on cardiotonic drugs without a weekly pulse check	7	(0.9)
10. Use of digoxin in absence of an acceptable diagnosis	36	(4.7)
11. Crushing of inappropriate medications	1	(0.1)
12. Medications administered without a corresponding order and/or at the designated times	10	(1.3)
13. Medication not charted as administered (for any reason)	1	(0.1)
14. Recommendation to discontinue medication	1	(0.1)
15. Initiation of antipsychotic(s) in absence of acceptable diagnosis	129	(16.8)
16. Antipsychotic use with no attempt at dosage reduction or behavioral monitoring in effect	16	(2.1)
17. Drug use with no documented diagnosis	478	(62.1)
18. Recommended dosage reduction	34	(4.4)
19. Other	4	(0.5)

The second type of cost savings would be averted costs. For example, a patient on warfarin therapy who is not monitored properly may suffer some type of bleeding episode. Costs associated with treatment of this drug toxicity would be averted if the pharacist's recommendations to institute monitoring were implemented before the bleeding began.

Potential cost savings were also quantified. These typically related to the condition of the patient and associated actions (if any) by the physician. For instance, the consultant pharmacist might question use of a drug for which no corresponding diagnois was present in the medical record. The physician might discontinue the medication and thereby produce a cost savings, or the physician might add a diagnosis to the chart, producing no dollar or patient care savings. The CliniTrend program places such interventions in a "Medical History Inquiry," where they are assigned a much lower dollar value.

Results

A total of 770 interventions were made as a result of performing DRRs in this skilled-care unit during 1994 and 1995. One or more interventions were made to the drug regimens of 378 of the 553 residents whose charts were reviewed during this time period. The types of interventions made are shown in Table 1. The most prevalent reasons for interventions included drug use with no documented diagnosis, initiation of an antipsychotic agent in the absence of an acceptable diagnosis, and lack of monitoring parameters for drugs that needed periodic monitoring.

Since the average length of stay in this unit was only about 12 days, we were unable to assess the acceptance rate of pharmacists' recommendations based on a once-a-month pharmacist chart review. Potential drug-cost savings as a result of pharmacist interventions totaled $18.02 per patient stay (Table 2). This resulted in an average predicted pharmacy drug cost savings of $14.42 for each intervention. Using an 80% acceptance rate by physicians to consultant pharmacist interventions, as reported by Miller,⁶ our interventions may have produced a potential drug cost savings of $7,972.73.

Table 2. Impact of Consultant Pharmacist Review on Patient Care in a Hospital-Based Step-Down Unit

1. Total no. charts reviewed	553
2. No. patients having interventions (249 women, 129 men)	378
3. No. patients with no interventions (121 women, 54 men)	175
4. Total no. interventions	770
5. Average intervention rate/patient (770 intervention/553 patients = 1.39)	1.39
6. Intervention rate percentage (378/553 = 68%)	68%
7. Average no. patients reviewed/month (553 pts/24 months = 23)	23
8. Potential pharmacy drug cost savings/study period	$9,965.91
9. Average potential pharmacy drug cost savings/patient DRR ($9965.91/553=$18.02)	$18.02
10. Predicted pharmacy drug cost savings (based on 80% acceptance rate)	$7,972.73
11. Average predicted pharmacy drug cost savings/intervention ($7,972.73/553=$14.42)	$14.42
12. Predicted pharmacy drug cost savings/patient/DRR ($14.42 x 1.39 = $20.04)	$20.04
13. Total average time spent per month for DRR	8 hours

Interventions associated with the highest cost savings involved dosage adjustments in residents with renal impairment, discontinuation or modification of duplicate medications for the same indications, and medication use without a corresponding diagnosis.

Discussion

Various studies have documented time and/or cost savings from a nursing standpoint, but we have not included this element in our study results.^3-5,7 In reference to "internal interventions," DeBoer and Gaither stated,³ "The dispensing pharmacist may have a greater role than the consultant pharmacist when making interventions at long-term care facilities whose patients are in the hospital before admission." Since our patients are transferred directly from acute care hospital beds to our step-down unit, the total monthly savings (based on consultant and dispensing pharmacists' interventions) would be greatly increased.

Table 2 shows that the consultant pharmacist intervened in the drug regimens of 68% of the skilled-care residents. This intervention rate is an important indicator of the special contribution of the consultant pharmacist in managing drug therapy, and the potential impact of his or her interventions on total patient care.

A skilled-care facility generally serves patients who will eventually move on to a LTCF or private home. Regulations governing the performance of the DRRs are identical for LTCFs and skilled-care facilities or step-down units. The majority of our resients experience a short stay. A short stay poses a particular challenge for consultant pharmacists who attempt to assess both the outcomes of their interventions or physicians' response rates. An alternative method of monitoring outcomes is necessary to accurately assess the impact of pharmacist interventions in the skilled-care setting.

This study had several limitations. Because of the short length of stay of our study population, we assumed an 80% physician acceptance rate for pharmacists' recommendations, which is a conservative estimate for our facility. The short length of stay prevented physicians from responding to some of our comments, since some patients were discharged before the pharmacists' notes were read. Our data and experiences from LTCFs in the area have consistently demonstrated a higher acceptance rate for our comments. Also, we did not produce an actual cost savings amount, as we quantified our data using the CliniTrend software program.

This report focused on pharmacy drug cost savings produced from decreased drug use in the skilled-care setting. Drug costs alone are not the only facet affecting total patient care; the potential for decreased drug-drug interactions, decreased length of stay, freeing up of nursing time, savings in averted ADR's and lab testing, decrease in pharmacy dispensing labor, averted costs associated with decreased physician visits, etc., all serve to further positively affect patient care.

The result of the monthly DRR generated 553 interventions by the consultant pharmacist. The potential pharmacy drug cost savings produced by these interventions totaled $9965.91 over the two-year period. Our current study was limited to a population with a high turnover rate (12 day average stay per patient). The total cost savings, then, would be greater than the calculated predicted drug cost savings ($7972.73), since ongoing interventions over a longer period (as in a purely skilled care facility) were not taken into account.

Conclusion

This report indicates that, by directly reducing pharmacy drug costs and indirectly affecting other therapies, consultant pharmacists may reduce the cost of care of short-stay residents such as those in the subacute care settings. More frequent interventions and increased prospective surveillance of medication orders before dispensing likely would increase the value of the pharmacists' activities.

References:

1. Drug regimen review: a process guide for pharmacists. American Society of Consultant Pharmacists, 1989: 1-24.

2. Helper CD. Future roles and responsibilities for consultant pharmacists. Consult Pharm 1989; 4(Suppl A): 41-50.

3. DeBoer LM, Gaither CA. Analysis of total pharmacy services offered to patients admitted to long-term care facilities. Consult Pharm 1996; 11:486-96.

4. Cooper JW. Effect of initiation, termination, and reinitiation of consultant clinical pharmacist services in a geriatric long-term care facility. Med Care 1985; 23:84-8.

5. Gebhart F. Research supports use of consultant pharmacists. Drug Top 1996; 140:76-8.

6. Miller SW, Marshall LL, Preston MW. Impact of pharmacist-conducted drug regimen review on drug use in an intermediate care facility. Consult Pharm 1991; 5: 317-22.

7. Cooper JW. Impact of consultant pharmacists on health care: past, present, and future. Consult Pharm 1988; 3:342-5.

Copyright © 1997, American Society of Consultant Pharmacists, Inc. All rights reserved.