The Effects of Managerial Intervention on Drug Prescribing Patterns at King Chulalongkorn Memorial Hospital Limpanathikul W, Wangsaturaka D, Nantawan P, Itthipanichapong C, Thamaree S, Withayalertpanya S, Ketcharoen A, and Tangphao O. Department of Pharmacology, Faculty of Medicine,Chulalongkorn University and Pharmacy Department, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Abstract: After Thailand economic crisis in 1997, King Chulalongkorn Memorial Hospital had to establish a new hospital drug list for reducing the drug expenditure. Generic prescribing and dispensing policies were also implemented at the same time. This study aimed to evaluate the impact of the new implementation by comparing the prescription patterns before and after the implementation. The prescriptions from the pharmacy outlets for the outpatient departments (OPDs) were systematically sampled five weeks before and after the implementation. Overall characteristics of the prescriptions including total number of prescriptions; items and cost of drug; average number of items/prescription; cost/prescription and cost/item; and the percentage of prescribed generic drugs were collected and analyzed. The total number of analyzed prescriptions and the average number of drug items/prescription before and after the hospital drug list were similar. However the total cost/prescription and the cost/item were decreased after the implementation ( Baht vs Baht and Baht vs Baht, respectively). After the generic prescribing and dispensing policy implementation, physicians in the hospital increasingly prescribed drugs by generic names (37.1% vs 44.85%). Locally made drugs were also prescribed by physicians and received by patients more than before (90.43% vs 84.27% and 60.72% vs 28.15%, respectively). From this short term study, it appears that the new hospital drug list and the generic prescribing and dispensing policies seemed to play a part on drug expenditure reduction. This implementation may also change the prescribing attitude of the physicians in King Chulalongkorn Memorial Hospital.

Background During Thailand economic recession ( ), public finance was cut including the public health care budget. The price of imported pharmaceuticals and medical equipments was also escalated due to Thai currency devaluation. There were several suggestions for reducing drug expenditure budget including restriction of hospital formulary or generic prescribing and dispensing policy. The economic crisis led the Ministry of Public Health (MPH) to set up

Background schedules for reducing drug items available in the National Essential Drug List (NEDL). King Chulalongkorn Memorial hospital also established a hospital drug list based on the new NEDL. The hospital pharmacists in collaboration with medical special list carefully selected drugs for the list. The new list was implemented on March 1 st, The generic prescribing and dispensing policy was also taken place at the same time.

The new hospital drug list of King Chulalongkorn Memorial hospital Drug listPrescribing limitation List 1 1 1R1 1R2 1R3 1R4 1R5 List 2 Reimbursable -essential drugs, prescribed by any physicians -prescribed by medical staffs -prescribed by only specialists -prescribed in In Patient Department (IPD) -narcotics and psychotropic drugs -prescribed under the permission of the director of the hospital Non-reimbursable

Objective This study aimed to evaluate the short term productivity of the new hospital drug list and the generic prescribing and dispensing policy by comparing the prescription patterns in out patient departments (OPDs) before and after the hospital drug list implementation.

Methods A retrospective-prospective descriptive study was carried out after the new hospital drug list implementation. Prescriptions within 5 weeks prior to the implementation from the pharmacy outlets for OPDs at King Chulalongkorn Memorial hospital were systematically sampling. During the on going implementation, the prescriptions were sampling in the same way from the same places for 5 weeks. The information from these prescriptions was collected and analyzed.

Results BEFOREAFTER Total No. of prescription2,0492,052 Total No. of items5,0844,983 Total cost of drug1,690,4841,282,343 Average No. of items/prescription Average cost/prescription Average cost/items Table 1. Characteristics of prescription before and after the implementation

GIBlood deriv Blood coag CVSRespi Antihis Neuromuscular Baht Fig. 1.1 The cost of drugs in each class

Anti- infective Antineo plastic Hormone Electrolyte EENTSkin unclassified Baht Fig. 1.2 The cost of drugs in each class

Cepha losporin Peni cillin Erythro mycin Tetra cycline Quino lone SulfaAnti fungal Antiviral Fig. 2 the cost of systemic anti-infective drugs Baht

Fig. 3 The percentage of prescribed drugs after generic prescribing policy % Generic name Trade name Combination drugs Hospital formulary

Fig.4 The percentage of prescribed and dispensed drugs after the generic prescribing and dispensing policy % Prescribed drugsDispensed drugs

conclusion From this short term study, it can be concluded that the new hospital drug list and the generic prescribing and dispensing policy can reduce drug expenditure at King Chulalongkorn Memorial hospital. If this implementation was maintained in the long run, it should be benefit for both the hospital and the country. However the quality of generic drugs under good manufacturing practice (GMP) and bioequivalence study is required. Acknowledgement -King Chulalongkorn Memorial hospital grant -personnel in the pharmacy department