Trend in revenue loss due to expired medication at a large urban hospital in Johannesburg, South Africa

A Research Report Submitted to the School of Public Health, University of the Witwatersrand in Partial Fulfilment of the Requirements for the Degree of Master of Public Health June 2016ntroduction Limited research has been conducted on the causes and economic impacts of expired medicine, yet medicine costs comprise a significant proportion of healthcare expenditure. Medicines and their management are an important health system function, necessary for improving and maintaining health. However the lack and wastage of essential medicine is still one of the most serious public health problems globally, including South Africa. The high rate of medicine expiry highlights a problem throughout the supply chain and this wastage reduces the quantity of medicines available to patients and therefore the quality of healthcare they receive. This study aimed to estimate the revenue loss due to expired medicines within a hospital setting from January 2011 to June 2014 and explore reasons for this. Methods This mixed methods study is a retrospective analysis review of forty-two months of expired medicine reports extracted at a public sector hospital coupled with a qualitative exploration (through semi-structured in-depth interviews) with key stakeholders about possible reasons for the expiration of medicines. In addition, informal observations were conducted across the duration of the fieldwork and recorded in a researcher diary. Ethics and research approvals for the study were obtained from the University of Witwatersrand Human Ethics Committee and the hospital. Results 32,368 medicines had expired over the study period. These data were drawn from the wards, outpatient departments and pharmacy and consisted of 68 different Anatomical Therapeutic Chemical (ATC) classes. More than 80% of the expired medicines were on the essential medicine list (EML) with antibacterial for systemic use (16%, n=5067) and antivirals for systemic use (15%, n=4970) among the highest classes that expired. The estimated total value of expired medicine for the study period was R838 029; an estimated annual revenue loss of 0.6% of the hospital’s total pharmaceutical expenditure; and an average increase in percentage revenue loss of 72% for the study period. Two main themes emerged from the in-depth interviews conducted with key stakeholders; i) Knowledge, understanding and practical application of policies and procedures related to expired medicines, and ii) Diversion from Ideal: procedures and constraints which may impact implementation. A closer examination to explore the reasons for these diversions - the ‘whys’- revealed three thematic areas: mistrust among employees and in the system, fear of being ‘caught’ yet lack of accountability and, ineffective communication and coordination. Discussion Expiry of medicines was highest among essential medicine on the supply-side. Medicines management is not restricted to pharmacists and although adequate tools for quantification and demand planning exist, none of these are focused on the health worker who has no formal training in medicine supply management. The study highlighted the need to identify effective strategies for phasing in and out of pharmaceutical policies and tenders to minimize waste. There is a lack of standard treatment guideline knowledge among prescribers. The extent of expired medicines at patients’ homes, patient returns or cost of disposing off expired medicine were not analysed. The relationship between governing documents and daily practices are not well understood by those responsible for managing medicines and accountability is not clearly assigned. Recommendations and Conclusion Creating awareness about the risk of medicines expiring and cost impact on service delivery should be communicated to healthcare workers and policy makers. Medicine supply management should be included as part of job descriptions of employees who manage medicines at this hospital to enhance accountability. Employing clinical pharmacists in the wards at tertiary hospitals may improve medicine management. Continuous monitoring and periodic evaluations to identify and address challenges related to medicine wastage is paramount to reduce financial loss and improve health outcomes. Sound coordination and communication is needed between the pharmacy and other departments in the hospital. Additionally, Pharmaceutical and Therapeutics Committees should emphasise the use of Standard Treatment Guidelines.MB201

Human papillomavirus (HPV) testing on self-collected specimens: perceptions among HIV positive women attending rural and urban clinics in South Africa

INTRODUCTION: Cervical cancer is the most common cancer among women in Sub-Saharan Africa. Cervical cancer is treatable if detected timeously, yet only 20% of South African women have ever been for a Pap smear in their lifetime due to limited access to screening, transport or child care responsibilities. OBJECTIVE: To evaluate the acceptability of self-collection for cervical cancer screening. We aimed to identify which self-collection device women prefer and if they would consider using them for routine cervical cancer screening. METHODS: HIV-positive women (>18 years) from urban and rural HIV clinics were interviewed following an education session on HIV, human papillomavirus (HPV) and cervical cancer. Participants were shown three self-collection devices; (i) an Evalyn cervical brush, (ii) a Delphilavager and (iii) a tampon-like plastic wand before completing a short questionnaire. RESULTS: A total of 106 women from the urban (n=52) and rural (n=54) clinic were interviewed. Overall 51% of women preferred the cervical brush, while fewer women preferred the tampon-like plastic wand (31%) or lavage sampler (18%). More than 75% of women from the rural site preferred the cervical brush, compared to 22% from the urban site (p<0.001). Women from the urban clinic preferred the tampon-like plastic wand (45%) and then the lavage sampler (33%), as compared to women from the rural clinic (19% and 4%, respectively). CONCLUSION: Women from urban or rural settings had different preferences for the various self-collection devices. Patient self-collection with HPV testing may be an acceptable way to improve coverage to cervical cancer screening in high risk HIV-seropositive women.http://www.panafrican-med-journal.comam201

The High Cost of HIV-Positive Inpatient Care at an Urban Hospital in Johannesburg, South Africa.

While most HIV care is provided on an outpatient basis, hospitals continue to treat serious HIV-related admissions, which is relatively resource-intensive and expensive. This study reports the primary reasons for HIV-related admission at a regional, urban hospital in Johannesburg, South Africa and estimates the associated lengths of stay and costs.A retrospective cohort study of adult, medical admissions was conducted. Each admission was assigned a reason for admission and an outcome. The length of stay was calculated for all patients (N = 1,041) and for HIV-positive patients (n = 469), actual utilization and associated costs were also estimated. Just under half were known to be HIV-positive admissions. Deaths and transfers were proportionately higher amongst HIV-positive admissions compared to HIV-negative and unknown. The three most common reasons for admission were tuberculosis and other mycobacterial infections (18%, n = 187), cardiovascular disorders (12%, n = 127) and bacterial infections (12%, n = 121). The study sample utilized a total of 7,733 bed days of those, 55% (4,259/7,733) were for HIV-positive patients. The average cost per admission amongst confirmed HIV-positive patients, which was an average of 9.3 days in length, was $1,783 (United States Dollars).Even in the era of large-scale antiretroviral treatment, inpatient facilities in South Africa shoulder a significant HIV burden. The majority of this burden is related to patients not on ART (298/469, 64%), and accounts for more than half of all inpatient resources. Reducing the costs of inpatient care is thus another important benefit of expanding access to ART, promoting earlier ART initiation, and achieving rates of ART retention and adherence

Survey of decisions RPEiS 32(4), 1970

Digitalizacja i deponowanie archiwalnych zeszytów RPEiS sfinansowane przez MNiSW w ramach realizacji umowy nr 541/P-DUN/201

Distribution of bed days by HIV status and reason for admission.

<p>Distribution of bed days by HIV status and reason for admission.</p

Correction: Initiating Antiretroviral Therapy for HIV at a Patient's First Clinic Visit: The RapIT Randomized Controlled Trial.

[This corrects the article DOI: 10.1371/journal.pmed.1002015.]

Baseline characteristics of admission cohort.

<p>Baseline characteristics of admission cohort.</p

Cost for HIV-positive admissions (HIV-positive only), by cost category in United States Dollars (USD).

<p>Cost for HIV-positive admissions (HIV-positive only), by cost category in United States Dollars (USD).</p

Summary of reasons for admission by HIV status.

<p>This figure presents the top 5 reasons for admission for each HIV status category. All other reasons were collapsed into the other category.* Tuberculosis was the most prevalent reason for admission amongst HIV-positive admissions accounting for 35%. CVD was the single most prevalent reason for admission amongst HIV-negative admissions accounting for 17%, while it only accounted for 4% of all HIV-positive admissions.</p

Box and whisker plot of CD4 count by reason for admission.

<p>The distribution of CD4 count at admission shows that all HIV positive admissions with one exception had a median CD4 count below 500 cells/mm³. This suggests that boosting the CD4 count of HIV positive patients by starting treatment early and ensuring adherence while on treatment may reduce the frequency and severity of admission.</p