Summary

1
COST IMPACT OF USING SPECIFIC CYCLOOXYGENASE II
INHIBITORS IN ORTHOPEDIC OUTPATIENTS AT LERDSIN
HOSPITAL Jitsuda Phosri M.Sc. in Pharm., Assist.
Prof. Vithaya Kulsomboon Ph.D. , and Assist.
Prof. Niyada Kiatying-Angsulee Ph.D. International
Graduate Program in Social and Administrative
Pharmacy, Faculty of Pharmaceutical Sciences,
Chulalongkorn University, Bangkok, Thailand

• Introduction
• Specific Cyclo-Oxygenase II (COX II)
  Inhibitors, have been introduced in several
  countries for the relief of chronic pain in
  rheumatoid arthritis and osteoarthritis.
  Celecoxib and rofecoxib are members of these
  specific COX II inhibitors, the incidence of
  gastric side effects with this new group is lower
  than observed in earlier NSAIDs.
• In Thailand, there had been an increasing
  trend of specific COX II inhibitors utilization
  expenditures on celecoxib dramatically increased
  from 45.1 million Baht in 1999 to 295.6 million
  Baht while rofecoxib expenditures slightly
  increased from 20.1 million Baht in 1999 to 155.8
  million Baht in 2001.
• The inappropriate prescribing of specific COX
  II inhibitors (COX II) has economic impact on
  individual patients and overall health care cost.

• Methods
• Research Design
• A retrospective Study during November 2002 to
  December 2002 in orthopedic outpatient clinic at
  Lerdsin Hospital, the Institute of Orthopedics of
  Ministry of Public Health, Bangkok, Thailand
• Subjects Instrument
• Data from orthopedic outpatient
  prescriptions and OPD Card that having specific
  COX II inhibitors and NSAIDs was collected,
  including, patients characteristics, patients
  histories and physicians prescribing.
• Data collection form was used to be instrument
  of this study.
• SPSS was used for analyzing the data.

• Abstract
• Problem Statement The inappropriate prescribing
  of specific COX II inhibitors (C2I) has economic
  impact on individual patients and overall health
  care cost.
• Objectives To characterize the patterns of C2I
  use and to determine its cost impact in patients
  who were at low risk and high risk for
  gastrointestinal adverse effects.
• Designs Retrospective design
• Settings Lerdsin Hospital, the Institute of
  Orthopedics of Ministry of Public Health,
  Bangkok, Thailand.
• Study Population Data from orthopedic
  outpatients having C2I and NSAIDs during November
  to December 2002 were collected. The
  proportionate sample was selected based on the
  two months drug utilization data including 519
  prescriptions of C2I and 594 prescriptions of
  NSAIDs. To select the prescriptions, computerized
  simple random sampling was used. The National
  Institute for Clinical Excellence of United
  Kingdom Guidance for C2I use was employed to
  determine whether the patients receiving C2I were
  at high risk of GI adverse events.
• Outcome Measures Total cost per prescription,
  average cost per prescription, average cost per
  day, mean duration of prescribed drug, and cost
  waste of C2I versus NSAIDs use in low risk group
  of actual practice and standard treatment.
  Additional cost of NSAIDs compared with C2I in
  high risk group of actual practice.
• Results Two hundred and eight (40.1) patients
  receiving C2I and 113 (19.0) patients receiving
  NSAIDs were considered to be at high risk for
  upper GI adverse effects. Of the patients
  receiving prescriptions for C2I, 112 (21.6)
  received C2I alone and 159 (30.6) received
  Gastro-Protective Agents (GPA) in addition to
  C2I. The results showed that prescribing of C2I
  compared with NSAIDs among patients who were not
  at high risk of GI adverse events resulted in
  excessive expenditure of 2.4 million Baht/year.
  Compared with the three highest consumption drugs
  in the hospital including diclofenac, Voltaren,
  and ibuprofen 400 mg, cost waste of C2I use were
  3.4, 1.7 or 3.2 million Baht/year, respectively.
  The additional cost of NSAIDs compared with
  celecoxib or rofecoxib use in the high risk
  group, practice, were 1.5 or 1.8 million
  Baht/year, respectively.
• Conclusions The cost impact of C2I use among
  patients who were at low risk for
  gastrointestinal adverse events compared with
  NSAIDs at Lerdsin Hospital was 2.4 million
  Baht/year. Because of the high cost impact of C2I
  use, it is necessary to employ clinical practice
  guideline for prescribing restriction and
  prospective drug use review for C2I.
• Funding Sources Graduate Program in Social and
  Administrative Pharmacy and Graduate School of
  Chulalongkorn University

• Objectives
• To characterize the patterns of use of specific
  COX II inhibitors in orthopedic outpatients at
  Lerdsin Hospital.
• To determine cost impact of using specific COX
  II inhibitors in orthopedic outpatients who are
  in low risk and high risk GI adverse effects.

Pattern of Drug Use
Figure 1 Pattern of Specific COX-II
Inhibitors Use in Orthopedic Outpatient
Department at Lerdsin Hospital

• Results
• Patient Characteristics
• Concerning age of patients, 35.1 of specific
  COX II inhibitors group and 15.3 of NSAIDs group
  were patients aged 65 years. From ?2 test,
  there was an association between age and patient
  receiving specific COX II inhibitors. The result
  showed that, number of patients aged 65 years
  receiving specific COX II inhibitors more than
  number of patients aged 65 years receiving
  NSAIDs (Plt 0.0001).
• Based on our observation, it appeared that the
  number of patient in CSMBS group received
  specific COX II inhibitors was greater than the
  number of patient who received NSAIDs. We
  conducted Chi Square test (?2) whether there was
  an association between CSMBS and patients
  receiving specific COX II inhibitors. The
  results showed that, the number of patients with
  CSMBS coverage receiving specific COX II
  inhibitors were greater than the others
  (Plt0.0001).

Cost Waste of Low Risk Group in Actual Practice
and Standard treatment
Table 2Cost Waste of Low Risk Group in Actual
Practice and Standard Treatment
Pattern of Drug Use in Low Risk and High Risk
Group
Table 1 Number of Prescriptions in Low Risk
and High Risk for Upper GI Adverse Effects of
Specific COX II Inhibitors and NSAIDs Using
during November 2002 to December 2002 of
Orthopedic Outpatients at Lerdsin Hospital.

• Conclusion
• Policy Recommendation
• Cost waste of specific COX II inhibitors in low
  risk group compared with NSAIDs was 2.4 million
  Baht/year in actual practice.
• Compared to Diclofenac, Voltaren? and Ibuprofen
  400 mg, excessive expenditures were 3.4, 1.7, and
  3.2 million Baht/year.
• Further study should focus on individual
  patients payment status to find our whether the
  payment status is a factor influencing physician
  prescribing.
• Pharmaceutical and Therapeutic Committee (PTC)
  should implement Drug Use Review (DUR) to
  evaluate specific COX II inhibitors use in
  clinical practice.
• The Clinical Practice Guideline (CPG) of
  specific COX II inhibitors should be reviewed in
  order to restrict specific COX II inhibitors use
  for high risk group only.

• Summary
• Pattern of Specific COX II Inhibitors Use
• Physician prescribed appropriate COX II use in
  high risk was 40.08 and inappropriate COX II use
  in low risk group was 59.92
• Cost Waste
• COX II compared with NSAIDs in low risk for
  actual practice 2.4 million Baht/year.
• COX II compared with NSAIDs in low risk for
  standard treatment e.g., Diclofenac 3.4 million
  Baht/year, Voltaren 1.7 million Baht/year and
  Ibuprofen 400 mg 3.2 million Baht/year.
• Additional Cost
• NSAIDs compared with specific COX II inhibitors
  in high risk for actual practice Celecoxib 1.5
  million Baht/year, Rofecoxib 1.8 million
  Baht/year.

• Discussion
• In this study, the most frequent prescribing was
  specific COX II inhibitors plus GPA or NSAIDs
  plus GPA. The results of this study were
  different from a previous study conducted by
  Phochanukul (1999), which demonstrated that the
  most frequent prescribing pattern was specific
  COX II inhibitors alone or NSAIDs alone.
• In Thailand, Pharmaceutical and Therapeutic
  Committee (PTC) should develop and implement
  prior authorization policy for appropriate
  specific COX II inhibitors utilization in the
  hospital. This policy would help saving
  substantial amount of money in long term.

Additional Cost of High Risk Group in Actual
Practice
Table 3 Additional Cost of High Risk Group in
Actual Practice
Celecoxib Gr. Rofecoxib Gr. NSAIDs Gr.
Total Cost (Baht) 77,589.12 118,956.06 26,776.67
Average Cost per prescription (Baht) 957.89 936.66 236.96
Mean Duration (Days) 31.17 27.24 21.36
Average Cost per Day Baht) 30.73 34.39 11.21
Number of Prescriptions 81 127 113
Additional Cost (Baht/year) 1,536,033.48 1,824,039.78 -