Role of Pharmacy on Alteration of Drug Cost and Drug-Related Problem Prevention for the National Health Insurance Geriatric Outpatient

Latifah, Sauriasari, and Firzawati: Role of Pharmacy on Alteration of Drug Cost and Drug-Related Problem Prevention for the National Health Insurance Geriatric Outpatient



The proper use of drugs can reduce the symptoms of the disease, prevent acute and chronic diseases and improve the health of patients.1 Nowadays the increased drug use is also impacted by the increasing misuse of drugs and increased occurrence of Adverse Drug Events (ADE). Improper use of drugs not only can lead to therapy failure, but it can also harm patients using these drugs.2 Geriatric patients are the biggest drug users compared with other age groups. Polypharmacy in geriatric patients may increase the prevalence of Drug Related Problems (DRP)3 and can be a major cause of patients admitted to hospital.4

The pharmacists have an important role in preventing of DRP in geriatric patients through clinical pharmacy services, including review the accuracy of each filled prescription. Studies demonstrated that pharmacist intervention can improve medication in elderly.5 The clinical pharmacy services also have an economic impact such as economic savings6 and cost avoidance.7 Economic savings refers to reductions in current spending, due to changes in the expenditure on a patient’s treatment.8 Cost avoidance refers to an intervention that reduces or eliminates additional expenditure that otherwise may have been incurred in the absence of the intervention.9 Indonesia has just taken a significant step in its efforts to roll out universal healthcare by established National Health Insurance (NHI) since 1 January 2014. NHI is a health insurance program carried out by the Indonesian government. This insurance provides the protection of public health in meeting the needs of basic health of the Indonesian population. Implementation of NHI using the National Formulary as a list of drugs chosen to ensure the availability of quality drugs. Clinical pharmacy services have an important role in the NHI era. These services are required to optimize the activities of pharmaceutical care, which is expected to prevent the occurrence of adverse events, over and undertreatment. Pharmaceutical care in the NHI era can encourage quality improvement in patient-oriented services.

The general state hospital in Depok city is a government hospital that serves NHI participant and has conducted the prescription review as one of the clinical pharmacy services. The prescription reviews were limited to administrative aspects and compliance of the prescription to the national formulary. This activity can be done by a pharmacist or a pharmacist’s assistant. The purpose of this study was to analyze the role of pharmacists and pharmacist’s assistants in altering drug costs through the prescription review of geriatric outpatient under NHI. Furthermore, the pharmacist will determine the cost avoidance through discussion groups.

Subjects and Methods

The samples in our study were taken from geriatric outpatient prescription in January until April 2016 in a general state hospital in Depok city. All prescriptions from geriatric outpatients (aged 60 years or more), who registered as NHI participants in the period of the study, which had been review by pharmacy staff (a pharmacist or a pharmacist’s assistant) were included. Prescriptions were excluded if illegible, had no diagnosis, had no details of prescription medication costs and when the patient did not get the medicine because of stock out. Sampling was done by purposive sampling.

This study was consisted of two phase. The first phase was done with observational, retrospective, and pre-post study design to analyze the role of pharmacists and pharmacist’s assistants in altering drug costs through the prescription review of geriatric outpatient under NHI. The second phase the discussion group were formed to assess the role of pharmacist in DRP prevention and determine cost avoidance. The discussion group consisted of 4 pharmacists who worked in this hospital. The purposes of this discussion group are to conduct a study on the clinical aspects such as prescription medication duplication, contraindications, drug interactions, indication the accuracy, dosage and timing of drug use. The pharmacists in this group give the recommendations on the DRP. Each pharmacist assesses 20 recipes drawn at random. The DRPs were obtained on this discussion group were further classified by PCNE V6.2.

Calculation of alteration in drug costs

Calculation of drug cost alteration was determined by calculating the difference in the cost of prescription after and before the review. Alteration of drug costs can generate cost savings when the cost of prescription after the review is smaller than the cost of the previous one. Formula calculation is carried out as follow:

Alteration of drug costs=Cost of prescription after prescription review-Cost of prescription before prescription review

The sample of calculation of drug cost alteration was shown on Table 1.

Using the formula above, the alteration of drug cost in table 1 are:

Alteration of drug costs=6,0817,418=(1,337)

The bivariate analysis performed to determine whether there is any difference between the cost of a prescription before and after review. Bivariate analysis was conducted using paired t-test if the data normally distributed or using Wilcoxon method if it is not normal.

Calculation of cost avoidance

The calculation of cost avoidance can be done using a method that has been used by Nesbit, as follows8

Cost Avoidance = probability of occurrence ADE x costs of an ADE

The cost of an ADE events based on the previous study was USD 53.10 When converted into rupiah, the cost incidence of ADE is Rp 698,434. The value of the probability of occurrence ADE was shown on Table 2.


A total of 682 prescriptions were reviewed by pharmacist and assistant’s pharmacist. 83 prescriptions were excluded because the prescriptions were illegible (16 prescriptions), there were no details of the cost of prescription medication (12 prescriptions), there were no diagnosis (36 prescriptions), and the patient did not get the medicine because of stock out (19 recipes). Total prescriptions that were analyzed in this study was 599 recipes. The characteristics of patients were described in Table 3.

Table 1

The sample of calculation of drug cost alteration

Before Prescription ReviewAfter Prescription Review

Drug nameQtyPrice (Rp)Total Cost of Prescription (Rp)Drug NameQtyPrice (Rp)Total Cost of Prescriptions (Rp)
Furosemide 40 mg797679Furosemide 40 mg797679
Spironolactone 25 mg83622,896Spironolactone 100 mg21,0352,070
Captopril 12.5 mg771497Captopril 12.5 mg771497
Aspilet 80 mg73672,569Acetylsalicylic acid 80 mg (Miniaspi)72942,058
Digoxin 0.25 mg7111777Digoxin 0.25 mg7111777
Table 2

Probability of occurrence of ADE to calculate cost avoidance

The probability of occurrence of ADEProbability scoreExample
Not harmful0.00Pharmacists recommend changes esomeprazole into omeprazole therapy due to cost considerations.
Very low0.01Clarification to the doctor due to incomplete information, such as clarifying the strength of the preparation, rules of use, dosage forms, etc.
Low0.10Interventions against drug administration at a dose of 2-4 x the normal dose, interventions against the drug dose is not sufficient to produce a therapeutic effect, the intervention of the time / improper use of drugs that could potentially lead to therapeutic failure or the occurrence of toxic effects, interventions against duplication therapeutic potential occurrence of toxic effects
Moderate0.40Interventions against drug administration with a dose of 4-10 x normal, intervention in dose adjustment in patients with renal failure
High0.60Intervention in the administration of drugs with 10 x the normal dose, intervention on the use of drugs with a narrow therapeutic index, intervention on the use of drugs that cause reactions anaphylaxis
Table 3

Patients Characteristics

CharacteristicsAmount n = 599 (%)
Man326 (54.4)
female273 (45.6)
Age (years) 
60-64219 (36.6)
65-69176 (29.4)
70-74135 (22.5)
> 7469 (11.5)
Diabetes mellitus74 (12.35)
Pseudophakic43 (7.18)
Stroke42 (7.01)
Congestive heart failure34 (5.68)
Cataract30 (5.01)
Etc376 (62.77)

Phase I

In the first phase, total alteration in drug costs in this study was Rp. 1,773,642 which corresponded to 3.78% from the total cost of prescription, before the prescription review. Table 4 show the 10 largest-alterations of drug cost, based on the diagnosis.

Phase II

In the second phase, the prescription review by the pharmacist in the discussion group obtained 16 cases DRP. The details were shown in table 5.

Based on the recommendations given by the pharmacist in the group discussions, only a recommendation to replace (8 recommendation) and to discontinue the use of a medicine (1recommendation) can produce the alteration in the drug cost. Prescription costs after a recommendation was given by the pharmacist were greater than the previous one. The addition of drug costs was Rp. 97,392 (Table 6). Total cost avoidance generated after a recommendation by a pharmacist in the discussion group is Rp. 1,466,711.4 (Table 7).


Our results in the first phase show that prescription costs after the prescription review were lower comparatively to the initial values. This shows that pharmacists and pharmacist assistants have an important role in economic impact, especially in cost saving. The value of cost savings generated in this study is not too large, amounting to 3.78% of the total cost of a prescription before the prescription review. This can be due to the fact that prescrition review only was done on the administrative aspects. Intervention by pharmacists and assistant pharmacists in this study consisted solely on drug substitution due to drug shortages or stock out, or when prescriptions were not in accordance with the national formulary. In a recent study from the value of cost savings derived from the active role of the pharmacist in pharmaceutical care activities tend to reduced overall drug cost, cost saving and cost avoidance.10 Based on the pharmacist’s recommendations in group discussions in the second phase, the cost of prescription after the recommendation was greater than the cost of the previous one. The cost increased to Rp. 97,392. This is because the drugs previously prescribed drugs that have replaced with more expensive prices. This case occurred on the replacement of fluoxetine with sertraline, amitriptyline with maprotiline, and replacement of fluoxetine with quetiapine. Selection of these drugs is expected to be safer for geriatric patients, so as to increase the effectiveness of treatment. Selection of sertraline is considered more appropriate for geriatric patients compared to fluoxetine. Administering drugs Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine was not the first choice in geriatric patients. Fluoxetine has a long half-life, so it can prolong the drug’s side effects. Fluoxetine also has a high risk to interact with other drugs. A safer option for the SSRI class of drugs in geriatric patients is citalopram, escitalopram or sertraline.11 Tricyclic antidepressants (TCAs) such as amitriptyline in geriatric patients was not the first choice for the consideration of side effects such as postural hypotension, and anticholinergic effects.11 Compared to amitriptyline, maprotiline has lower anticholinergic effects and weaker affinity for the receptor α1.12 Total cost avoidance generated after a recommendation by a pharmacist in the discussion group is Rp. 1,466,711.4. This suggests although the change in drug costs become greater after recommendation by the pharmacist, but these recommendations can prevent ADE costs significantly. Although the prescription review in general state hospital in Depok city just limited on the review of administrative aspect, but it can lead to reduced cost prescription and result in cost saving. The optimization in pharmacist role is very important to prevent DRP in geriatric outpatient and also can lead cost avoidance.

Table 4

The 10 largest drug cost alteration by diagnosis

No.DiagnosisPrescription Cost (Rp)Alteration in Drug Costs (Rp)
Before Prescription ReviewAfter Prescription Review
3Lower back pain1,194,5241,021,826(172,698)
4Diabetes mellitus10,496,90110,325,786(171,115)
5Congestive heart failure2,064,2221,925,140(139,082)
8Chronic Obstructive Pulmonary Disease (COPD)124,57512,836(111,739)
9Osteoarthritis (OA Genu)331,736238,479(93,257)
Table 5

DRP Classification based on PCNE V6.2

Undesirable events (non-allergic) (P2.1)16
Inappropriate Drugs Combination (C1.3)11
 • The use of acetylsalicylic acid (anti-platelet) with meloxicam7
 • The use of quetiapine with risperidone1
 • The use amitriptyline with fluoxetine1
 • The use of fluoxetine with clozapine1
 • The use of fluoxetine with risperidone1
Improper duplication (C1.4)5
 • The use of two Non-steroidal Anti-Inflammation Drug (NSAID) (mefenamic acid and sodium diclofenac)5
Inform the doctor (I1.1)9
Provide drug counseling in patients (I2.1)7
Changing medications (I3.1)8
Stopping treatment (I3.5)1
Table 6

Prescription drug cost alteration, based on the recommendation of pharmacists

No.Prescription Cost (Rp) 

Prior Prescription Review and Recommendations PharmacistsAfter Prescription Review and Recommendations PharmacistsAlteration in Drug Costs (Rp)
Table 7

Cost avoidance generated by pharmacist intervention

Type of RecommendationFrequency RecommendationProbability scoreCost Avoidance (Rp) (The probability of ADE x Rp. 698. 434 x Frequency Recommendation)
Drug Interaction40.41,117,494.4
Duplicate use of NSAIDs50.1349,217
Total Cost Avoidance1,466,711.4


In conclusion, optimization of pharmacists’ roles can generate significant economic benefits (cost savings and cost avoidance) in NHI era.


The authors would like to thank to general state hospital in Depok City, especially for Pharmacy Installation for helping to supply the data in this study.

This study was financially supported by PITTA Grant, Universitas Indonesia (No. 1825/UN2.R12/HKP.05.00/2016) and we are thanks to DRPM (Directorate of Research and Community Engagement) Universitas Indonesia for their assistance.


[1] Conflicts of interest CONFLICT OF INTEREST Authors do not have any conflict of interest.



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