|Year : 2022 | Volume
| Issue : 1 | Page : 56-62
Cost analysis of outpatient department prescriptions in the community pharmacies during the coronavirus disease-2019 pandemic in Maharashtra
Sharon Reji, Preeti Santosh Mishra, Salman Retiwale, Prasanna R Deshpande
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed to be University, Pune, Maharashtra, India
|Date of Submission||21-Oct-2021|
|Date of Decision||29-Jan-2022|
|Date of Acceptance||05-Feb-2022|
|Date of Web Publication||30-Jun-2022|
Prasanna R Deshpande
Poona College of Pharmacy, Bharati Vidyapeeth Deemed to be University, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Community pharmacy is a place under the direct supervision of the pharmacist where the prescription orders are compounded and dispensed. In India, there are limited studies published on the economic evaluation of community pharmacy. This study aimed to conduct a cost analysis of outpatient department prescriptions in the community pharmacies during the coronavirus disease-2019 pandemic on various parameters such as the total cost, average cost/prescriptions, age-wise cost, prescribers, drug class, pharmacy wise, route of administration, and diagnosis cost.
Material and Methods: The analysis of total and average cost per prescription was conducted. The study was carried out for 6 months during. The number and type of drugs prescribed and the frequency and total cost of the prescriptions were noted. Statistical analysis was conducted for different demographics and various parameters.
Results: A total of 1166 prescriptions were analyzed in the study. Out of 3704 drugs prescribed 99.9% were branded ones. The average number of drugs/prescriptions was 3.17. The predominance of male patients (60%) was seen. On the overall cost of prescriptions the statistical significance of the overall cost was established at (P < 0.00001). The sum of all the prescriptions accounted for ₹.10, 86,504.65. The average cost/prescription was ₹.931.82.
Conclusion: The average total cost/prescription was found to be higher in our study. There is a need for further studies to be done in the field of community pharmacy.
Keywords: Community pharmacy, cost analysis, health economics, India, outpatient department
|How to cite this article:|
Reji S, Mishra PS, Retiwale S, Deshpande PR. Cost analysis of outpatient department prescriptions in the community pharmacies during the coronavirus disease-2019 pandemic in Maharashtra. Indian J Community Fam Med 2022;8:56-62
|How to cite this URL:|
Reji S, Mishra PS, Retiwale S, Deshpande PR. Cost analysis of outpatient department prescriptions in the community pharmacies during the coronavirus disease-2019 pandemic in Maharashtra. Indian J Community Fam Med [serial online] 2022 [cited 2022 Aug 17];8:56-62. Available from: https://www.ijcfm.org/text.asp?2022/8/1/56/349391
| Introduction|| |
The World Health Organization announced the novel coronavirus disease-2019 (COVID-19), a pandemic on March 11, 2020. In India, during March 2020, the number of infected cases was 62 which gradually attained its peak by April 2021.
Cost analysis is a pharmacoeconomic evaluation in which the costs of two or more alternatives are compared without were the outcome., About 60% of the population in India (499–649 million) do not have regular access to essential medicines. The fact that India produces 8% of the medicines available on global markets in terms of volume and ranks 13th in terms of production value is not enough to explain this disparity. In India, 80% of outpatient care is provided by the private health sector. Therefore, a cost analysis study is a significant and simple tool of conducting a pharmacoeconomic evaluation.
The need of this study is the deficient or less number of research in community pharmacy, pharmacist's role, economic load, and its impact on the population during the pandemic. There are limited studies published in India on community pharmacy activities. A total of 30 papers in the duration of 10 years (1998–2008) on Indian community pharmacy topics (three papers per year) represent a very low rate of publication in this field.,,,,,,
| Material and Methods|| |
This was an observational study. Conducted between September 2020–February 2021. The margin of error for the samples was calculated using the Raosoft calculator. The error was 2.79% with a confidence level of 95%. Prescriptions were collected from three different pharmacies which covered a total of 18 prescribers. Convenience sampling method was used to select prescriptions.
- Prescriptions from the community pharmacies, i.e., private medical shops located in vicinity of the hospitals.
- Patients visiting the community pharmacies to purchase medicines for various ailments.
- Inpatient department prescriptions
- Follow-up prescriptions
- Medicolegal cases.
The prescriptions were collected were from three different pharmacies in Maharashtra as per our convenience. Prior consent from the pharmacy owners was obtained for data collection. Informed consent from all the patients willing to take part in the study was obtained. The outpatient department (OPD) prescriptions taken were from the community pharmacies which were located near the hospitals (as per the OPD timings) and clinics. These pharmacies were from Mumbai (Mulund and Kalyan) and Pune (Hadapsar) located in Maharashtra. Data were then entered into the logbook according to a predesigned pro forma which includes OPD No./Bill No., prescriber's name, patient demographics, suspected diagnosis, drug name (generic and brand), dose, and dosage form. The maximum retail prices of the drugs were used from www. 1mg.com while analyzing the cost. The costs of the medicines were calculated in Indian rupees.
The data of 1166 prescriptions collected were systematically entered into Microsoft Excel for calculating the total cost of each drug in a tabular form. The dose of each dosage form was maintained in mg unit for uniformity of the data.
For example, a dose calculation for Alkacip Syrup 1.53 g/5 ml in 100 ml bottle is calculated using simple cross multiplication, therefore the dose in 100 ml is 0.30 mg.
The total cost of the prescriptions was broken down based on each pharmacy, patient demography, diagnosis, drug class, route of administration, dosage forms, and cost on prescribers.
The statistical analysis was done using Microsoft Excel, Social Science Statistics, and GraphPad Prism 9.2.0. The cost of prescriptions was grouped from 1 to 500, 501–1000, >1000, and the statistical test was conducted. The statistical tool used to analyze the patient gender was Mann–Whitney U-test, while the other cost were correlated using Chi-square test for independence.
Ethical approval (BVDUMC/IEC/44) dated June 25, 2021, was obtained for the study by the Ethics Committee of Bharati Hospital and Research Center, Pune.
| Results|| |
A total of (1166) prescriptions were collected for the study. The drugs prescribed in total were 3704, out of which 99.9% were branded drugs. The average number of drugs/prescriptions was 3.17. The overall total cost of the prescriptions was ₹.10, 86,504.65. The average total cost/prescription was ₹.931.82.
The majority of prescriptions were for between the age of 31–40 (27%) and 41–50 (22.8%) were the most likely to be prescribed. Males outnumbered females (60%). The overall cost of prescriptions was higher for age group of 51-60 years [Table 1].
It was observed that the prescriptions which were consisting of four drugs had the highest cost, while those prescriptions with 11 drugs were valued the least because the cost of some drugs such as paracetamol and metformin were low [Table 2].
The total cost of each prescriber varied with the number of prescriptions [Table 3].
|Table 3: Total cost distribution of prescriptions as per the prescribers|
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[Table 4] summarizes the distribution of total cost according to the drug class. The total cost of the prescriptions has a higher value because the drugs prescribed were from the class of cardiovascular systemic agent (17%), anti-infectives (13%), gastrointestinal agents (11%), nutraceuticals (11%), antidiabetic (8.69%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (3.75%). The other classes such as immunosuppressants (steroids), central nervous system agents (antipsychotics), antihistaminic, respiratory agents (bronchodilators), vaccination, etc. costs were the lowest.
There was a positive correlation between the cost and the number of drugs. The data were highly significant at P < 0.00001 in spite of having drugs that had a low cost [Table 5].
The three pharmacy sites were located across various sections of Maharashtra, with Site 3 being in the metropolitan area. As the number of prescriptions and medicines increased in each pharmacy, the overall cost of each site grew simultaneously. In comparison, with the total cost of Site 2, i.e., ₹1, 25, 785.11 (11.5%), the total cost incurred by Site 3 is ₹.5, 90,305.19 (54.3%) is the highest. The average total cost/prescription in Site 1, Site 2, and Site 3 was ₹.815.89, ₹.590.54, and ₹.1182.97, respectively, as shown in [Figure 1].
[Figure 2] illustrates the prescription-wise distribution of the various routes of administration, along with their overall cost. The frequency of prescriptions administered orally was 66.9%, and the total cost was 55.63%, with surgical prescriptions having the lowest total cost, i.e., 0.25%. Second, the total cost of the oral + topical combination is 6.7 times cheaper than the overall cost of the prescriptions (₹.10, 86,504.65).
|Figure 2: Total cost distribution according to the different routes of administration. (Oral – O, Parenteral – P, Surgical – S, Topical – T, Others – OT)|
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The total cost evaluated on monotherapy valued more than that of the combination therapy of the specific dosage forms, as mentioned in [Figure 3].
[Figure 4] depicts that the majority of prescriptions (n = 203) being diagnosed were for infection and its total cost was 14% compared to the other prescriptions with ear, nose, and throat related diseases were 1%. There is a direct relation of the total cost with the number of prescriptions having the infection.
|Figure 4: Total cost distribution according to systemic involvement and diagnosis.(CVS – Cardiovascular System, GI – Gastrointestinal, CNS – Central Nervous System, ENT – Ear, Nose, Throat)|
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The GI agents, antidiabetic drugs, and NSAIDs were frequently prescribed in combination and it resulted in the total cost exceeding the monotherapy. The total cost of CVS agents in combination was on a higher side which was contradicting the total cost of rosuvastatin and atorvastatin as monotherapy in [Figure 5]. 1.83% of the total cost was spent on multivitamins, while Vitamin C, when prescribed alone, was 0.4%.
|Figure 5: Total cost distribution of drugs in different drug classes (Monotherapy vs Combotherapy)|
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| Discussion|| |
Despite the fact that the study was done in three community pharmacies, a total of 18 prescribers, referring to 18 separate study locations and 1166 prescriptions were included in the study. The evaluation of prescription costs at the pharmacy level is focused on in this study.
Lower sample sizes were utilized in the research by Ashraf et al. (n = 386), Vineeta et al. (n = 309), Narwane et al. (n = 600), Shanmugapriya et al. (n = 700), Upadhyay et al. (n = 182), Atal and Atal (n = 304), Rajathilagam and Sandozi(n = 130), and Aravamuthan et al. (n = 1052). Prescription analysis was performed in a hospital setting in the above trials. Orzella et al. conducted a research in Italy (n = 3,620,361) that evaluated a sample size of the complete population to calculate the overall cost.
The prescriptions belonging to the age group 31–40 (27%) were majorly seen in our study similar to <40 years (21.2%) by Shanmugapriya et al., but the study by Ashraf et al. had the majority of the patients from the age group 11–25 years.
The predominance of males (60%) is higher in our study and the same was found in the studies by Vineeta et al., Ashraf et al., Narwane et al., Shanmugapriya et al., Upadhyay et al., and Rajathilagam and Sandozi, etc. The comorbid conditions were mostly found in males which can be a cause for the rise in the prescriptions of males.
The total cost of pharmacy as mentioned in [Figure 1] gives an insight of the average cost/prescription, but there are no supporting articles found to be compared. The average cost/prescription on Site 3 was ₹.1182.97 which was slightly higher compared to the other sites due to the increasing demand for clinics and OPDs in the vicinity, while the average cost/prescription on Site 2 was less (₹.590.54) because it belongs to a retail generic pharmacy. The comparison was not established as there were no supporting articles on this.
The total cost of the 1166 prescriptions in our study was ₹.10,86,504.65 (Indian rupees), but the costs incurred in the other studies by Ashraf et al. (₹.20,408.88), Atal and Atal (₹.157867.2), and Rajathilagam and Sandozi (₹6,66,510) were much lesser due to fewer sample size. Although the Indian government has said that generic drugs should be prescribed, 99% of the drugs in our survey were branded. This supports the idea that the sale of generic medications is not practised. The average cost/prescription by Atal and Atal (₹.519.30), Upadhyay et al. (₹.723.60), and our study (₹.931.82) was lower, the average cost/prescription by Rajathilagam and Sandozi (₹.5127).
The total drugs prescribed in our study were 3704 which is higher compared to the other studies by Upadhyay et al. (685 drugs) and Shanmugapriya et al. (2069 drugs). In comparison to our study, a large number of drugs were prescribed by Aravamuthan et al. (3936). In our study, the average number of drugs per prescription was 3.17 which was similar to the study by Atal et al. and Upadhyay et al. (3.76) but was slightly less in a study by Shanmugapriya et al. The highest average number of drugs was seen from the study by Rajathilagam and Sandozi (11.8) and Singla et al. (7.25). The total cost of prescriptions varies with the quantity of drugs and the number of prescriptions.
In our study, the major cost was spent on drugs consumed orally (60%), parenteral (12.64%), topicals (2.03%), surgical (0.25%), and others (0.14%). The majority of oral dosage was seen in the study by Ashraf et al., Narwane et al., Upadhyay et al. (94.89%), and Singla et al. (80%), while the total cost of syrups being prescribed as monotherapy (1.09%) was greater than its combination therapy. The reason behind this observation might be that syrups are more commonly available as combination therapy rather than monotherapy, which led to an increase in the cost of monotherapy.
Among the prescribers, the highest total cost was prescribed by the prescriber having 206 prescriptions which was ₹.1,94,597.55 (17.91%), while the least total costs by the prescriber having 6 prescriptions were ₹.3,564.44 (0.33%). In conclusion, as the prescriptions expand, the total cost by the prescriber also increases simultaneously.
The total cost of infection was higher than the other diagnosis, this was similar to the study by Aravamuthan et al.. The total cost of infection could be risen due to the frequent episodes of having cough/cold/fever in the COVID scenario.
The drugs were classified as per the pharmacological drug classification. The costliest drugs dispensed were from the CVS (16.89%) drug class, while the least was from the class of antipyretic (0.24%). This finding is similar to the study of Rajathilagam and Sandozi The cost of combination therapy is higher in the following drug classes: CVS agent, GI agent anti-infectives, antidiabetics, and NSAIDs since the combination therapy has a higher therapeutic effect and multiple pharmaceutical active ingredients.
Our study was done in the pandemic scenario where the demand for drugs was higher in the community pharmacy. The patient load in the OPDs was less in comparison to the pre-COVID situation. The surplus demand for multivitamin, CVS agents, and GI agents was seen. Each prescription had some nutraceutical and a prophylactic agent prescribed to combat the virus subsequently increasing the total cost of prescriptions. There are very few studies conducted on the cost analysis of prescription in the community pharmacy during the pandemic which made it difficult to compare the study.
There are certain limitations to this study. For instance, the OPD prescriptions obtained were from community pharmacies in Maharashtra; hence, the data may not reflect the cost of prescriptions incurred both outside and within Maharashtra. Due to the time restrictions in the OPDs, there were only a few patients each day, and so, the prescriptions were limited. Prescriptions from the OPDs could be generic, but the community pharmacy dispensed them as brand medications. As majority of pharmacies dispense medicine at a lower rate compared to MRP, the amount quoted in MRP cannot be fully considered as the actual cost paid by the patients.
| Conclusion|| |
The key finding of our study denotes that the average total cost/prescription was ₹.931.82 which is comparatively high. The majority of drugs dispensed were branded which increases the total cost per prescription. In the pandemic scenario, the demand for drugs such as multivitamins, cardiovascular agents, gastrointestinal agents, and anti-microbials increased. The patient load in the OPDs decreased compared to the pre-COVID time period, but the pharmacies were crowded as they were considered as the primary source of treatment during the pandemic. The price in the different pharmacies of Maharashtra had a major difference. Further research is required for better understanding of the economics in a community pharmacy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]