1. 1 DRUG DATABASE AND PERFORMANCE INDICATORS FOR UTILIZATION MONITORING Authors: Pongcharoensuk P 1, Angsanant M 2, Chantrakunopars P 2, Phuthong P 1, Kongsawat S 1 Institution: 1 Mahidol University; 2 Ministry of Public Health, Thailand Problem Statement: Drug expenditure accounts for 30% of health resources in Thailand. For health care administrators, a standard drug database and management system are essential for utilization monitoring at both national and facility levels. Objective: To determine key performance indicators for drug utilization monitoring. Design: Retrospective, time-series design. Study Population: Twenty-six government hospitals (size range, 10–1,000 beds) with complete electronic drug purchasing database for fiscal years 2000–2002, were purposively selected. Intervention: Different drug codes (of similar drug products) from different hospitals were transformed into the same standard drug code. Using the standardized drug codes, drug purchase data from all 26 hospitals were consolidated to develop key performance indicators. Outcome Measures: Total drug purchase (in baht), ratio of essential drugs (EDs) to nonessential drugs (NEDs), and drug purchase by pharmacological group were used to monitor utilization trends. Unit price statistics of generically equivalent drug products in 2002 were used as indicators for price monitoring of individual product. Results: More than 100,000 drug purchase transactions were gathered. Results showed an increase in total drug purchase from 817.8 million baht in 2000, to 908.3 million baht in 2001, and 978.4 million baht in 2002 (11.0% growth in 2001 and 7.7% in 2002). Also increased was the ratio of NEDs to EDs—15:85 in 2000, 17:83 in 2001, and 18:82 in 2002. For pharmacological classification, anti-infectives ranked first in total purchases for all three years but with a decreasing percentage, from 30.0% in 2000, to 26.4% in 2001, and 23.6% in 2002. Cardiovascular drugs ranked second in total purchases but with an increasing percentage, from 11.4% in 2000, to 12.4% in 2001, and 13.7% in 2002. In unit drug price (baht) statistics for 2002 (listed in the following order: number, average, standard deviation, minimum, maximum, p50, p75, p90), a wide variation was found among both multisource and single-source drugs as follows: aledronate 10 mg tab—48, 48.99, 6.78, 45.86, 81.68, 48.15, 48.15, 48.15; ceftriaxone 1 g inj—22, 36.62, 22.74, 20.18, 124.12, 31.03, 37.98, 56.15; and simvastatin 10 mg tab—66, 4.72, 1.92, 2.00, 8.92, 4.24, 5.35, 7.68. Conclusion: Although not standardized, the drug database available in Thai hospitals can be a valuable resource for utilization monitoring and system management to increase efficiency and effectiveness.

2. 2 Introduction Drugs accounts for 30% of health expenditures in Thailand. Public hospitals are major health service providers including pharmaceutical services. In each hospital, drug database (such as purchase and utilization records) has been kept accumulating for many years. However, these drug databases have limited utility for national policy-making due to the lack of standard structure and code as well as inadequate information technology in data management. Hospital and health care administrators need to use these available data as monitoring tools for decision making and management at both national and facility levels.

3. 3 Objective To determine key performance indicators for drug utilization monitoring: 1. Trend monitoring –Total purchase, ratio ED:NED –Total purchase by drug group, etc. 2. Price monitoring –Unit price* statistics (mean, standard deviation, min, max, percentile 50, 75, 90, 95) of generically equivalent drug products. * Unit price is net purchase price per unit (tablet, bottle).

4. 4 Methodology Study design: retrospective, time-series design. Study Procedure I. Construction of Standard Drug Code (25 digits) –Type (Single* or combinations), 1 digit –Drug Name, Paracetamol, 10 digits –Dosage form, Tablet, 3 digits –Strength, 500 mg., 4 digits –Company, GPO, 4 digits –Package size, 100 tab, 3 digits *Only single chemical entity drug code is available for this study.

5. 5 II. Data collection Sample: 26 public hospitals (10-1000 bed) were puposesively selected. They had complete records and were willing to provide a copy of Electronic Drug Purchasing Database of the year 2000-2002. III. Data transformation Different drug codes (of the same drug product) from different hospitals are changed into the same standard codes. IV. Data consolidation and analysis All the transformed drug purchasing data from 26 hospitals were consolidated and then analyzed using Microsoft Access, Excel and SQL. Methodology

6. 6 Results: Key performance indicators I. Total drug purchase (million baht) of 26 hospitals in 2000-2002. ----------------------------------------------------------- Year Purchase %change (adjusted*) (adjusted*) ----------------------------------------------------------- 2000 817.8 2001 908.3 (898.4) 11.0 (9.9) 2002 978.4 (947.7) 7.7 (5.6) ---------------------------------------------------- Notes: *adjusted for inflation of 1.1% in 2001 and 1.9% in 2002 (NESDB).

7. 7 II. Drug Purchase as % of Total Operating Expenses in 2002 ------------------------------------------------------------- Type of Hospital (bed) N Range % Avg. ------------------------------------------------------------- Regional (500-1000) 7 15.6-29.4 20.7 General (200-500) 14 11.2-27.2 18.3 Community (10-90) 5 12.5-19.6 17.5 ------------------------------------------------------------- (The bigger the hospitals, the more drug used)

8. 8 III. Total Purchase Ratio of Non-Essential Drug (NED) and Essential Drug (ED) --------------------------------------------- Year Ratio (NED:ED) --------------------------------------------- 200015 : 85 200117 : 83 200218 : 82 ---------------------------------------------

9. 9 IV. Ranking of Drug Purchase (%) by Pharmacological Groups ------------------------------------------------------------- Rank Group*2002 2001 2000 ------------------------------------------------------------- 1Anti-bacterials21.6 23.8 26.6 3Anti-asthma 4.0 4.4 3.9 4Anti-diabetics 3.9 3.3 3.0 5Hypo-lipidemic 3.3 2.8 2.4 6Anti-anaemic 3.3 2.7 2.1 8NSAIDS 2.5 2.6 2.0 10Cytostatic 2.2 1.7 1.4 ------------------------------------------------------------- Total (million) 824 779 730 ------------------------------------------------------------- *A total of 125 groups

10. 10 V. Unit Purchase Price (baht) Statistics of Generically Equivalent Products of 2002 --------------------------------------------------------------- Drug # Min Max Avg p50 p75 --------------------------------------------------------------- Aledronate 10 mg tab 48 45.9 81.7 49.0 48.2 48.2 Alprazolam.25 mg tab44 0.2 5.0 0.7 0.5 0.8 Atorvastatin 20 mg tab32 50.3 58.4 52.3 50.3 52.3 Captopril 25 mg tab 27 1.4 26.3 6.1 7.5 7.5 Cefoperazone 1 g inj 65 220 487 422 486 486 Ceftriaxone 1 g inj 22 20.2 124 36.6 31.0 38.0 Ciprofloxacin 250 mg tab59 1.2 14.1 4.2 3.8 5.4 Simvastatin 10 mg tab 66 2.0 8.9 4.7 4.2 5.4 Rosiglitazone 4 mg tab 12 57.3 87.9 59.9 57.3 57.3 ---------------------------------------------------------------- Notes: Italics are single-source drugs

11. 11 Discussions Lesson learned An urgent need for data management of available hospital database to be utilized for drug system management and policy implementation. Policy implications Structure - A central data warehouse under the Ministry of Public Health, with capability for huge data management. - An agency for determination and maintaining of standard drug codes (possibly FDA?). Process - In addition of Quantity indicators of drug purchase as shown, Quality indicators of drug use are necessary to guarantee good outcomes for the patients and economic outcomes for providers.

12. 12 Conclusions Though not standardized, hospital drug database can be a valuable source for improving system efficiency and effectiveness of drug use. Recommendations More research to be pursued: –Quality of drug use and cost consequences of an illness, particularly chronic diseases such as diabetes or asthma. –Quality of drug use and outcomes of treatment. –Systematic management of drugs (selection, procurement, utilization and outcomes). This study is supported by the National Health Security Office.