Cost-efficiency of Clinical Pharmacy Services at Ministry of Health Hospital, Riyadh City, Saudi Arabia

Yousef Ahmed Alomi* , The Former General Manager of General Administration of Pharmaceutical Care, Former Head, National Clinical Pharmacy and Pharmacy Practice. Former Head, Pharmacy R&D Administration, Ministry of Health, Riyadh, SAUDI ARABIA. Sultan Mohammed Al-Jarallah, Head, Ambulatory Care Pharmacy, Oncology and Hematology Clinical Pharmacist, Pharmaceutical Care Department, Security Forces Hospital, Riyadh, SAUDI ARABIA. Faiz A. Bahadig, Informatics Pharmacist, Pharmaceutical Care Department, King Abdul-Aziz Medical, City-WR-Jeddah, Ministry of National Guard, SAUDI ARABIA.


INTRODUCTION
The clinical pharmacy services was started in the Kingdom of Saudi Arabia in the late-1970s, 1,2 whereas it was started at the Ministry of Health hospitals in the mid-1980s. 1,2 Several clinical pharmacy services founded at that time included but not limited to the drug information services, therapeutic drug monitoring services, rounds with clinical teams and total parental nutrition. 1,2 The clinical pharmacy services focused on drug information, formulary management system, antibiotics monitoring and rounds with medical and surgical teams. After several years of starting clinical pharmacy services, the measurement of impact of the services on patient care and on the healthcare system was investigated in Saudi Arabia. Previously, several studies have illustrated the clinical outcome and economic impact of critical pharmacy services. 3 Some investigations focused on, for instance, drug information services, therapeutic drug monitoring services and on total parenteral nutrition. [4][5][6][7][8] Other studies have focused on the general clinical activities, for instance, pharmacists interventions and prevention of medications errors. [9][10][11][12][13] The studies on the general clinical pharmacy services on the measurement of economic impact investigated overseas countries; however, to the best of our knowledge, there are no similar studies conducted in the Saudi Arabia, Gulf and Middle Eastern countries. 14-17 Therefore, in this study, we aimed to explore the cost-efficiency of clinical pharmacy services in Riyadh city, Saudi Arabia.

METHODS
This is a simulation study which included data of all 5 months of providing clinical pharmacy services to adults organized by local drug information center at public hospital, in Riyadh city, Kingdom of Saudi Arabia. In this study, 10 clinical pharmacists and expert trained pharmacists provided clinical pharmacy services which included drug information services, poisoning control services, therapeutic drug monitoring services, orthopedic services, oncology pharmacy services, pharmacoeconomic services and pain management services. All pharmacists should document the clinical pharmacy activities on a monthly basis; the clinical activities consisted of central clinical pharmacy activities, patient-specific clinical pharmacy activities, administrationspecific clinical pharmacy activities and time spent for each activity. 3,16,18 The clinical pharmacy program was established during the mid-1980s at the biggest public Ministry of Health hospital.
The hospital has 1400 beds and three hospitals: public, pediatrics and maternity and obstetric hospitals. The hospital had started with two clinical pharmacists at medical and surgical wards. Then, the services were expanded to cover drug information services and drug researches. In 1998, nutrition support pharmacy was started for adult patients. During 2008-2012, the clinical pharmacy services expanded with more than 10 clinical pharmacists. Currently, more than 20 clinical pharmacists provide pharmaceutical care in the hospital. The author calculated the estimated cost avoidance by using two International Studies Model, expressed in terms of US dollars (USD); the costs avoidance considered were the expected results of drug-related problems of drug information inquiries, poisoning information calls if not resolved and cost avoidance of pharmacist intervention for all other clinical pharmacy services. 19,20

RESULTS
A total average estimated monthly cost avoidance from all clinical services (13,166,198.59 USD) with cumulative cost avoidance was 65,830,992.97 USD during the study period. The estimated total cost avoidance annually was 157,994,383.08 USD. The highest cost avoidance came from poisoning services, whose estimated cost avoidance was 51.4% (6,832,519.80 USD), followed by drug information services, whose estimated cost avoidance was 26.59% (3,533,455.13 USD) and other clinical pharmacy services, whose estimated cost avoidance was 11.32% (1,504,833.47 USD) of the total. The average estimated avoidance/occupied bed was 9404.43 USD, whereas the poisoning services was 4880.37 USD and drug information was 2523.90 USD and other clinical pharmacy services was 1074.88 USD (Table 1). Each USD invested in the clinical pharmacist estimated cost avoidance was an average of 107.84 USD. Each USD invested in the clinical pharmacist provides poisoning control services estimated cost avoidance was an average of 55.96 USD. Each USD invested to the clinical pharmacist provide drug information services estimated cost avoidance was an average of 28.94 USD. Each USD invested to the other clinical pharmacist provides other clinical pharmacy services estimated cost avoidance was an average of 12.32 USD (Table 1).

DISCUSSION
Clinical pharmacy program has been established at the biggest Ministry of Health hospital since mid-1980s. 1,2 The hospital has 1400 beds and three hospitals: public, pediatrics and maternity and obstetric hospitals. The hospital was started with two clinical pharmacists at medical and surgical wards. The services were expanded to cover drug information and drug researches. In 1998, nutrition support pharmacy was started for the adult patients. During 2008-2012, the clinical pharmacy services was expanded with more than 10 clinical pharmacists. More than 20 clinical pharmacists provide pharmaceutical care at all hospitals. In this study, the authors tried to estimate the cost of clinical pharmacy services through the clinical pharmacists. The findings showed a highcost impact of clinical pharmacy services. Our results were lower than the previous study because of the well-established services at the study site studies, whereas it was newly established at our current site. 15,16 The maximum high-cost impact was from drug information and poisoning services. Therefore, these services have been provided for a long time in the current study site, whereas the other clinical activities or services were newly founded. The estimated cost avoidance per occupied bed was higher than the previous study, whereas it was lower than the updated study. This is related the incremental number of hospital in the study and well-established clinical pharmacy services. 15,16 The rate of cost invested in saving money was higher than the previous study. 15 Because there maybe high number or intervention or the potential of the interventions of newly established clinical activities. Moreover, the hospitals had very few newly appointed clinical pharmacists with more active and more involvement in the f the therapeutic plan. In addition, the hospital missed to follow several therapeutic guidelines at that time; that's may lead more intervention and correction the inappropriate medication usage. The clinical pharmacy services at the local hospital are cost-efficient and need to expand the services to cover all beds to provide best care to the patients.

CONCLUSION
In this study, clinical pharmacy services were cost-efficient at biggest public hospital in Riyadh city, Saudi Arabia. This is associated with cost savings per clinical pharmacist. In future, we recommend to expand the clinical pharmacy services with electronic documentation, related to preventing drug-related problems, emergency units visiting and drug-related hospital admission. In addition, cost avoidance simulation should be performed for healthcare improvement and better care, better patient outcomes and reduced costs.