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14 West African Journal of Pharmacy (2013) 24 (1)

Cost Minimization Analysis of Antibacterial Therapy in a Developing Country

1 2Ismail A Suleiman and Fola Tayo 1Department of Clinical Pharmacy and Pharmacy Practice, Niger Delta University, Wilberforce Island, PMB 071,

Bayelsa State, Nigeria. 5600012West African Post Graduate College of Pharmacists

Corresponding author: Ismail A Suleiman email: [email protected] phone no: +234 802 343 3337

ABSTRACTBackground: There is the need for improved efficiency and minimization in cost of antibacterial therapy in developing countries. The study objective was to carry out cost minimisation analysis of antibacterial in a tertiary health care facility in Nigeria between the year 2005 and 2006.

Methods: Drug utilization review was carried out using prescriptions in 525 consecutively sampled case notes of some infectious diseases retrospectively. Relevant data such as demographics, diagnosis, prescribed drugs, and dosages were extracted. Cost per defined daily dose of each drug, the cost of each prescription and the average cost of antibacterial agents per patient were determined. This was followed by economic evaluation using Cost Minimization Analysis. Data were analysed appropriately.

Results: Amoxicillin and coamoxiclav for ENT infections and ciprofloxacin/doxycycline for STIs were the most widely utilized. Generic products, higher strength, solid dosage forms and oral formulations are more cost effective than branded agents, lower strength, liquid formulations and injections of the same drug entity respectively. For instance, the use of generic product of ciprofloxacin for 5 days for 1000 patients (5000DDDs) resulted in a cost saving of NGN1.04million (USD9,333.33).

Conclusion: Only few drug items were predominantly responsible for high antibacterial therapy costs which need to be closely monitored for cost to be appreciably minimized. Generic antibacterial agents, higher strength preparations of the same drugs, solid forms in preference to syrups among school age children and oral agents in preference for injection should be used. Significant cost could be minimised and improved access to essential drugs assured if these are followed.

Key words: Cost Minimization Analysis, Pharmacoeconomics and Antibacterial Therapy

INTRODUCTIONEconomic evaluation of therapy is increasingly being advocated in developed countries to ensure maximum return in health for limited resources

1available. However, in most developing countries such as Niger ia cr i t ica l considerat ion of pharmacoeconomic principles is limited or does not

2exist. Where cost minimization related matters are mentioned or discussed, there are often no evidence-based data for definite conclusion. In today's competitive and limited resource health care environment, choices and tradeoffs in providing

3,4health care services are inevitable. In most developing countries, quality of health care services are below acceptable standard. In addition, the cost of health care is prohibitive and borne mostly from out of pocket expenses. Meanwhile, poverty is on the increase. "In Nigeria, the spontaneous reporting system (SRS) is widely used but has evidence of significant and widespread under-reporting of ADRs". - the highlighted "the" should be deleted and the sentence reads - "In Nigeria, spontaneous reporting system (SRS) is widely used but has evidence of significant and widespread under-reporting of ADRs".

West African Journal of Pharmacy (2013) 24 (1) 14-21

West African Journal of Pharmacy (2013) 24 (1) 15

cost option(s), which could be useful in making decisions as well as in policy formulation.

METHODSSetting and Study designThe study was carried out in a Lagos based teaching hospital, with about 10,000 patients' monthly turnover. It was a retrospective study applying Cost Minimization Analysis (CMA). Five hundred and twenty five out-patient case notes were consecutively sampled over one year period (between the year 2005-2006) for three categories of disease conditions that had antibacterial agents as the mainstay of therapy. These include tuberculosis, sexually transmitted and ear nose and throat infections. Pharmacoeconomic comparators

a) Generic versus branded agents of the same chemical entity.

b) Different strengths of the same drug productc) Solid versus liquid formulations of the same

drug for older childrend) Oral dosage form versus injection of the same

drug.Pharmacoeconomic objective, Perspective of analysis and Outcome measures Which of the stated options would minimize cost of antibacterial therapy? Economic outcome alone were considered as clinical and humanistic outcomes are the same among the various comparators. The economic outcomes include the cost per defined daily dose and cost of therapy. There was no adjustment for discounting and inflation as all the costs occurred within one year of analysis.

Data collection and analysisRelevant data such as date of visit, demographics, diagnosis, type of diagnostic test, prescribed drugs, and dosages, frequency of dosing as well as duration of therapy were extracted. Follow-up visit if any, test of cure (a repeat diagnostic test within a month of therapy to ascertain complete eradication of infection or otherwise) were also collected using an appropriately designed and validated data collection forms. Average wholesale price of each drug obtained through a market survey was used. The data were analysed using Epi Info (CDC, 2002). Mean cost per defined daily dose (C/DDD) and the total cost of antibacterial agents per visit for each patient were computed for each drug. Defined daily dose has been recommended for analysis

13,14,15of drugs . Also determined were the proportions of prescriptions in generic and branded names. Results were presented using descriptive statistics (means and

Line 19 - sentence - " Global HIV/AIDS Initiative Nigeria (GHAIN) is funded by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S Agency for InternationalDevelopment (USAID)... . ." the highlighted "is" should be replaced with "was" and the sentence now reads - "Global HIV/AIDS Initiative Nigeria (GHAIN) was funded by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S Agency for International Development (USAID)....Previously, emphasis is basically on clinical outcomes of therapy with little critical consideration for economic and humanistic (psychosocial) outcomes

8(ECHO) of health care services, which has been 9recommended in economic evaluation of therapies.

Increasing consumer (patient) expectation and their interest for improved efficiency has influenced the health care environment to re-focus and be more cost effective in orientation.Cost Minimisation Analysis (CMA) also referred to as Cost-Cost Analysis is a typical pharmacoeconomic methodology that is applicable when alternatives being compared have equivalent outcomes or are

10assumed to be so. Infectious diseases have a great impact on the health and well being of man because of their communicable nature. Antibacterial agents, the mainstay of therapy in infectious disease management are good candidates for economic appraisal and represent a sizable proportion of drug budget. In addition, they can lose their potency to resistance rapidly, thereby shortening their useful life span. Non-affordability of the required quantity of appropriate drug(s) by patients to ensure complete eradication of the infecting organisms has serious implications on the health and wealth of the nation because of worsening quality and shortening quantity of life in severe cases. Delay, poor management or non-treatment leads to complications, development of antibacterial resistance, increased cost of health care, increased morbidity and mortality and spread due to their externality. Therefore, useful interventions that can reduce cost and encourage affordability would go a long way in poor countries like Sub-Sahara Africa, where dropping out of antibacterial therapy has been

11reported. WHO in 2006 also pointed out that one-third of global population has no access to good

12quality medicines. Despite the challenges of meeting the rising cost of health care, there is paucity of evidence based data for well informed health/drug policies and decisions.The objective of the study was to determine the actual cost of the various comparators to identify the lower

CMA of Antibacterial Therapy


percentages). Data in proportion (percentages) were analysed using chi square test and Fisher's exact test (for small numbers) while mean costs were compared using student't' test. At 95% confidence interval, a 2-tailed p-value less than 0.05 was considered significant. In addition sensitivity analysis which involves alteration of economic outcome in favour of lower cost options to know the extent of cost minimization was carried out.

RESULTSAntibacterial UtilizationPenicillins were the most widely prescribed antibacterial agents for Ear Nose and Throat (ENT) infections at a rate of 35.5% with amoxicillin either alone or in combination with clavulanic acid constituting 23.8%, followed by cephalosporins such as cefuroxime (12.1%) and macrolides predominantly erythromycin at a rate 10.3%. The cost of penicillin was 24.9% of total antibacterial cost. Cephalosporin constituted 48.4% of antibacterial cost. For Sexually Transmitted Infections (STI), quinolones mainly ciprofloxacin were the most widely utilized (31.1%) followed by tetracycline predominantly doxycycline at a rate of 29.2% and erythromycin, a macrolides (11.5%). The quinolones constituted 34.1% of the antibacterial cost in STI therapy followed by macrolides which constituted 17.5%.

Proportion of drugs prescribed in generic and branded names were 82.1% and 17.9% respectively for Sexually Transmitted Infections but for Ear, Nose and Throat infections the values were 34.1% and 65.9% for generic and branded respectively. The differences were

2statistically significant (p


2

Table : Cost/DDD of Different strength of the Same DrugDrugs Dose (DDD) Mean Cost/DDD NGN(USD) P Value

250mg 500mg Ciprofloxacin tab 250mg b.d 52.000 (0.34) < 0.05 Ciprofloxacin tab 500mg b.d 152.00 (1.13) 104.00 0 (0.69) < 0.05 Erythromycin tab 250mg q.d.s. 4800 (0.32) 32.000 (0.21) < 0.05 Erythromycin tab Amoxicillin cap

Coamoxiclav tab Coamoxiclav tab

Metronidazole tab Metronidazole tab

500mg q.d.s 500mg tds

*375mg bd *625 mg bd

200mg tds 400mg tds

96.000 (0.64) 120.0020 (0.8) *375mg 214.280 (1.43) 428.560 (2.86) 200mg 12.000 (0.08) 24.000 (0.16)

64.00 0 (0.42) 90.0010 (0.6)

*625mg 150.000 (1.00) 300.000 (2.00)

400mg 7.500 (0.05) 15.000 (0.1)

< 0.05


DISCUSSIONFew antibacterial agents from different classes and some dosage form(s) are predominantly responsible for high cost of antibacterial therapy and focusing interventions on them will assist a lot in cost minimization drive of the health sector and drug policy in particular.Cost Minimisation Analysis (CMA) showed that the use of generic product of ciprofloxacin for susceptible organisms at a dose of 500mg 12 hourly for 5 days costs NGN760,000.00 (USD5066.67) for 1000 patients (5000DDDs) and NGN1.8million (USD12000.00) for the branded. The difference is very significant (p


as otitis media which is very common among school age children. Otitis media prevalence rate of 14.7% in

23children 0-12 years of age and 30.6% across all age 24group as well as a total antibacterial drug cost for

7.7million cases of otitis media in excess of NGN6.3 billion (USD 49milliom) and total therapy cost of

25about NGN13billion (USD 100milion) annually have been reported. Oral forms (tablets or capsule) also saves costs relative to injection (p


ACKNOWLEDGEMENTThe cooperation of the teaching hospital management, physicians, pharmacy staff, laboratory staff, medical records staff and nurses of the hospital is highly appreciated.

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