الفهرس 
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Abstract
Clinical Pharmacists play a vital role, which aims to minimizing drug therapy problems (DTPs) guaranteeing drug safety and reducing drug cost without negatively affecting morbidity and survival indices.
Worldwide, healthcare systems are coming under increasing pressure due to several causes as aging populations, chronic diseases and proliferation of new expensive medical care resources.
As most of DTPs occur due to scarcity of therapeutic information which causes an increase in the cost of treating the resulted complications, the demand of involving clinical pharmacist in the health care system is rapidly increasing especially in developing countries where the medical services placed a large burden on the health authorities.
Many studies have been conducted to evaluate the clinical pharmacist’s interventions (CPIs) in preventing or at least minimizing DTPs, making patient-specific tailored recommendations and improving the quality of care. However, only few had assessed the economic impact of CPIs in addressing these issues.
All healthcare services need to show that they provide value for the investment made in their provision. Economic evaluations are required to create robust evidence for evaluating the need for implementation and continuation of clinical pharmacy services.
Drug therapy problems are considered as a major problem associated with hospitals. It is a wide term that includes:
Improper number or indication of prescribed drug.
Incorrect selection of the most effective drug for the patient according to the most recent guidelines and patients’ specifications.
Drug-drug interactions.
Drug side effects that threaten patient safety.
Inaccurate dosing regimen and frequency.
Absence of instructions for preparation and administration.
6.1.1 The objective of this study is: to describe the clinical pharmacist interventions that optimizing the utilization of drugs and assess the economic impact of pharmacist recommendation regarding DTPs namely dosing regimen and indication of the drugs in the ministry of health hospitals in Alexandria.
6.1.2. Study design: Multi-centers retrospective record review in closed units (ICUs PICU, NICU), inpatients (including surgical and dialysis units), outpatient’s clinics, and burn units, of sixteen Ministry Of Health hospitals with clinical pharmacy services in Alexandria.
Summary, Conclusion and Recommendations
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Microsoft Excel sheet was used to tabulate the data and calculate positive, negative and overall benefits of clinical pharmacists’ interventions using IBM (SPSS) ® software package version 20 for statistical analysis.
6.1.3. Statistical analysis:
6.1.3.1. Descriptive statistics: For Clinical pharmacists’ interventions (CPIs) and physicians’ responses to CPIs in Ministry of Health (MOH) hospitals during the study period.
6.1.3.2. Bi-variate analysis:
Pearson’s chi-square was used to test whether the acceptance of CPI significantly varies by type of the intervention and type of department.
One-way ANOVA conducted for testing the effect of the department and type of DTP on benefit of CPIs.
6.1.3.3. Multivariate analysis:
Multiple logistic regression model to detect whether physicians’ probability of acceptance significantly differs by type of DTPs, by department and by type DTP in every department. Bootstraping multiple linear regression to detect whether mean benefit significantly differs by type of DTPs, by department and by type DTP in every department.
6.1.4. Economic analysis
Only interventions about the indication of the drug and dosing regimen were considered for economic impact evaluation as they exceeded more than two-third of all CPIs as resulted from the pilot study.
The analysis was conducted from the governmental perspective (health care payer perspective). Direct medication costs and pharmacists’ salaries were included. Adjustments were made to bring all costs and benefits to 2018 EGP for analysis, although all results were reported in 2020 EGP.
Cost- benefit analysis (CBA) was performed to estimate the economic benefits of the CPIs where costs and benefits were expressed in monetary values.
6.1.4.1. Cost
To estimate the cost of the intervention, the cost of pharmacist time (in terms of salary) was used.
6.1.4.2. Benefits
To estimate the financial benefits of CPIs, added or saved drug costs resulted from the intervention were calculated.
When drug costs were reduced due to the CPI; benefits are positive. On the other hand, benefits are negative when the CPIs resulted in increased drug costs.
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Benefit –cost ratio BCR: compared the outcome of clinical pharmacists’ interventions defined as total benefit to its cost expressed in term of monetary unit.
Net benefit of the interventions is the defining as difference between total benefits and interventions’ costs.
6.1.4.3. Probabilistic Sensitivity Analysis (PSA) was conducted to test the robustness of the benefit –cost ratio and net benefit with estimation of the uncertainty surrounding them.
6.1.5. Results
A total of 23,448 interventions were documented by the clinical pharmacists during the 18-month period in 16 MOH hospitals.
Analysis of the type of the drug-therapy problems (DTPs) revealed that, drug indication was the most common DTP in all settings (8,096) accounting for nearly 35% of the total CPIs. The second most frequent type was dosing regimen (8,000) 34%, followed by monitoring of the drug effects, selection of the most appropriate drug and special instructions for preparation /administration. Interventions related to drug interaction and patient’s adherence were the least.
Total interventions related to drug indication and dosing regimen DTPs were 16,096 interventions, which represents 69% of the CPIs screened during the study period.
Among interventions related to drug indication DTP, removal of unnecessary drug accounted for two-thirds of the interventions, and addition of a new drug accounted for the remaining one third. The majority of the interventions addressing dosing regimen DTPs were related to dose modification (93%).
Nearly half of interventions took place in the ICUs, followed by inpatient department.
The overall acceptance rate 74%.Acceptance rate significantly varied by different department, by DTP type and by interaction between them. Burn units had the highest acceptance rate among all settings, (90%).Regarding DTP type, dose modification was the most accepted with acceptance rate 79%.
Bootstrap -based linear regression analysis revealed that; the mean benefit of accepted target CPIs significantly varied by DTP by department, and by their interaction.
During the study period, out of 11,950 accepted CPIs, interventions with positive benefits were 7,473 representing 63%.The total net benefit from target accepted CPIs was EGP 4,263,340 and the mean benefit was EGP 357 (SD 2,846).
Base case analysis results showed that, clinical pharmacists had positive economic impact. Per intervention, the benefit was higher than the cost by EGP 183, translating into an annual net benefit of EGP 1,963,224. The benefit to cost ratio was more than 1 (BCR 3.23). This mean that for every EGP spent on CPI, there is an average benefit of EGP 3.23.