Drug-Related Problems: Once A $76.6 Billion Headache, Now A $177.4 Billion Migraine

Tom English

Pharmacy Today. 2001;7(3) 

Introduction

If the 1995 Johnson and Bootman research that pegged the cost of ambulatory drug-related problems (DRPs) at $76.6 billion raised eyebrows, an update on that study in the current issue of the Journal of the American Pharmaceutical Association (JAPhA) should cause shock waves. Even assuming that the likelihood of adverse outcomes has not increased, the rising cost of health care has brought the direct cost of DRPs to an astounding $177.4 billion.

Scope of Problem More Important Than Numbers

Employing the same probabilities and model used in the original Archives of Internal Medicine study, Frank R. Ernst, PharmD, and Amy J. Grizzle, PharmD, of the University of Arizona College of Pharmacy (COP) set out to bring new focus to the discussion of DRPs. They updated the cost-of-illness estimates during the intervening period, one notable for its intense scrutiny of the medication use process and other types of medical errors. Since the Johnson and Bootman study, the Institute of Medicine issued a report suggesting major system-wide changes to reduce medical errors and Congress has wrestled with designing a prescription drug benefit for Medicare patients.

"It has been at least 5 years since the extent of the problem was first estimated, and understanding something about the trend, alluded to by our research, may be useful to decision makers and shapers of policy within the health care system," Ernst said during an interview with Pharmacy Today.

Research conducted before 1995 focused on increased rates of hospital visits due to nonadherence to medication regimens and identifiable adverse drug events. But J. Lyle Bootman and Jeffrey Johnson also incorporated DRPs such as untreated indications, improper drug selection, drug interactions, and overdosage, all medication problems identified in pharmaceutical care research of the early 1990s. In their analysis of "the silent disease of America," possible therapeutic outcomes included no treatment, physician visit, additional treatment, emergency room visit, hospital admission, treatment in a long-term care (LTC) facility, and death.

When released, their findings were dubbed a "$76.6 billion headache." In other papers and news reports, Johnson and Bootman estimated that 40% of the costs -- and 120,000 deaths -- were preventable through increased efforts of pharmacists to assure proper medication use. Since Ernst and Grizzle used the same model employed by Bootman and Johnson, change in health care costs is the prevailing factor in the estimated cost increase, and the assumptions about prevention would be the same.

Neither research team claimed that their estimates are exact dollar amounts associated with DRPs. Rather, they sought to estimate the scope of the problem. The cost-of-illness model employed was one way to illustrate which areas of health care might be most important to address when trying to understand the costs of DRPs, Ernst told Pharmacy Today.

The Ernst and Grizzle estimate, adjusting costs to 2000 dollars, reflects skyrocketing expenditures in health care, especially for hospitals and long-term care (LTC) facilities. The average cost of a hospital admission was 134% higher, rising from $5,415 in the 1995 paper to $12,646 in the Ernst and Grizzle study. The average LTC admission cost rose 108% (from $4,571 to $9,489), and expenses for physician visits and new prescriptions went up 70% and 68%, respectively. Only the cost of an emergency room visit fell slightly.

Ernst said that costs rose more quickly than might be explained by normal increases in prices, such as are estimated by the Consumer Price Index. "It is difficult to know why hospital costs increased more than the other costs we calculated. Costs are not always recorded the same way each year or in different hospital settings, so the data we used may reflect more expensive procedures being performed, higher operating costs allocated across shorter hospitalization stays, fewer numbers of hospitalized patients, or any number of other possibilities," said Ernst, an Eli Lilly Health Outcomes Fellow at the University of Arizona. "The costs are average costs, and very expensive health care for some patients is, therefore, not separated from the costs for patients who require very inexpensive health care."

Increasing overhead costs due to increased regulation and other factors could have contributed to the rise in LTC cost more than previously recognized, Ernst speculated, but the study was not designed to quantify any of these aspects of the cost of illness.

The Pharmaceutical Care Factor

Johnson and Bootman wrote in their paper that a 10% reduction in negative therapeutic outcomes "could lead to a substantial savings to the health care system and to society as a whole," and that "pharmaceutical care may provide the basis on which health care professionals can make that impact." National pharmacy leaders applauded these words. More cautious, Ernst and Grizzle noted only that "pharmaceutical care may have an impact on reducing DRPs, as may other considerations."

Ernst agreed that pharmaceutical care should still be a "major" consideration in health care, and that its effect on overall cost savings is worth looking at in a separate study. Asked about the "may have an impact" statement in the paper, Ernst said the impact of pharmacists' patient care role has not diminished.

"However, pharmacists are undoubtedly more burdened by insurance requirements, increasingly stressful work environments, and the shortage of fellow pharmacists, among other things. I am not certain how much more pharmacists can do on their own, but many pharmacists can be seen doing their part to tackle the drug-related morbidity and mortality problem in their own practice settings," Ernst said. "Finding innovative and effective ways to illustrate the financial value of pharmaceutical training in order to gain further cooperation from other segments of the health care community may be one way to empower [pharmacists] to contribute more toward reducing the costs."

Bootman was not surprised about the increase in DRP costs, noting that Ernst and Grizzle have "demonstrated an interest in continuing our investigation into this most serious problem, which is still a crisis in the American health care system." He said that more work needs to be done to evaluate interventions, and that the elected officials on Capitol Hill should listen to what these new numbers signify.

"I am increasingly concerned that passage of a prescription drug benefit for elderly patients without financial incentives that reimburse health care professionals for minimizing DRPs will compound these problems even further," Bootman said.

Researcher Calls Medication System 'Slipshod'

In a JAPhA editorial commenting on the importance of theErnst and Grizzle article,David Bates, MD, chief of the division of general internal medicine and primary care at Brigham and Women's Hospital in Boston, wrote, "The main message is clear: The costs associated with drug-related problems in America's currently slipshod medication system are already enormous and appear to be growing rapidly. Only through a national focus on drug-related problems will researchers be able to conduct the studies needed and implement the identified solutions in everyday medical and pharmaceutical care."

The specific cost estimates "must be taken with a grain of salt because of the assumptions involved," Bates warned. He noted that Bootman and Johnson's study received criticism because data for some categories were sparse. He also called Ernst and Grizzle's claim that no important new information was available to allow changes in the incidence estimates "questionable." Nevertheless, he gave all the authors high marks for attempting to aggregate the cost of DRPs.

During an interview with Pharmacy Today, Bates said he had expected the overall price tag to increase but not more than double. He attributed the $121.5 billion estimate for hospitalization costs to the closing of small hospitals and the resulting higher costs of admission to larger hospitals. LTC figures went up because costs for all services have increased over the years and America has a growing aging population, Bates said.

An advocate for increasing research dollars for investigating and solving DRPs, Bates thinks that improvements such as computerized prescribing, better systems for identifying why a patient stops taking a medication, and enhanced communication between patients and providers on adverse effects need to be addressed "one hill at a time." His research has shown benefits from pharmacist involvement in patient rounds and fewer errors when physicians use automated systems to enter medication orders.

"If this is done, the health care system could work substantially better and be more efficient," Bates said.

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