Costs are not the bottom line in drug choices

Ease of use should follow outcomes in importance

Hitt, Catherine M, et. al. Cost comparison of single daily i.v. doses of ceftriaxone versus continuous infusion of cefotaxime. Am J Health Syst Pharm 1997; 54:1,614-1,618.

Drug costs are often the bottom line for hospitals choosing a therapy regime, but labor and supply costs and the regime’s impact on staff and patients should be given serious weight in the selection analysis.

That’s the message from researchers comparing therapy methods for patients with serious bacterial infections treatable with either of a pair of third-generation cephalosporins: cefotaxime or ceftriaxone.1

The study compared the costs of a single daily IV dose of ceftriaxone with the approved continuous IV infusion of cefotaxime. Specific-ally, the drug and ancillary costs of a single 1 g dose of ceftriaxone over 30 minutes vs. a 2 g continuous infusion of cefotaxime were analyzed. (On day one of cefotaxime therapy, an additional 1 g was administered for 30 minutes as a loading dose. That cost was included in the overall analysis.) Researchers entered the study using a standard dosage rate of 1 g every 24 hours of ceftriaxone and 1 g every eight hours of cefotaxime.

Both drugs have been shown to be effective in treating a host of infections, including meningitis, bacteremia, and lung, bone, and joint infections.2 And while single daily doses of ceftriaxone have been compared with multiple daily doses of cefotaxime,3 this study looks at continuous infusion of cefotaxime as a cost factor.

The continuous infusion of cefotaxime proved less expensive overall than single daily IV doses of ceftriaxone by about $10 a day after day one of each therapy. This was true despite the fact that cefotaxime therapy was more costly in terms of supplies and labor time than that of ceftriaxone therapy. And that’s where hospitals need to determine which savings is best for them, and which therapy is best for patients.

Cost analyses in detail

Pharmacist, technician, and nursing labor times were included in the study, along with supply costs, including conventional and ADD-Vantage infusion bags, conventional and pump-specific tubing, and labels, needles, syringes, and flush adapters. In terms of labor, pharmacists were timed entering orders for both therapies and checking the preparation (drug and dosage verification and labeling) done by technicians, based on the use of a conventional or ADD-Vantage system.

Tech and pharmacists times combined spent preparing doses for the two systems came to 1.9 minutes for a conventional and 1.2 minutes for the ADD-Vantage system.

Nurses were timed as they administered the two drugs per the two bag systems, coming to a similar 2.0 and 2.2 minutes respectively for the conventional and ADD-Vantage systems. But true to the study’s labor detail, an additional 5.3 minutes were needed for nurses to monitor the continuous infusion of cefotaxime, driving up the overall labor cost over that of ceftriaxone therapy by $2.20 a day.

Tubing proves costly

Tubing costs were a major factor studied by the researchers at Mayo Medical Center in Rochester, MN, because the institution’s pump costs are built into tubing costs. Conventional IV set tubing came to 46 cents a day, or $1.37 overall based on 72 hours of use. The continu-ous infusion tubing needed for cefotaxime therapy, though, came to $1.73 a day, or $5.20 for 72 hours of use. Tubing costs were deemed the major difference in supply costs in the study, based on the higher expense of continuous infusion tubing.

(Regardless of which therapy was chosen, the use of ADD-Vantage bags increased supply costs by $3.75 over conventional bags, although potential waste of drug associated with the conventional bags was not considered.)

Also, in terms of supply and monitoring costs, with ceftriaxone therapy, a basic standard of venous catheter flush with .9 percent sodium chloride before and after dosing, and the use of 1 mL of heparin sodium solution to maintain the catheter between doses was factored in.

Wholesale drug costs were as follows:

Ceftriaxone:

— 1 g ADD-Vantage vial — $30.04;

— 1 g conventional vial — $29.10;

— 10 g conventional bulk vial — $283.64.

Cefotaxime:

— 1 g ADD-Vantage vial — $8.86;

— 1 g conventional vial — $9.08;

— 10 g conventional bulk vial — $79.35.

Also included in cefotaxime wholesale costs are 2 g ADD-Vantage vial at $16.16 and 2 g conventional vial at $16.79 to reflect the day-one-only inclusion of a 1 g loading dose. (The chart on p. 189 breaks down the wholesale costs into a daily cost comparison.)

Taken as a whole, although the cefotaxime therapy was cheaper, researchers noted that monitoring time and ease of administration factors for the nursing staff, and the greater patient mobility that comes with single daily doses of ceftriaxone, along with the pump and related supplies on hand, are the major considerations for each institution choosing an antimicrobial therapy.

[For more information, contact Catherine Hitt, PharmD, Drug Information Specialist, Mayo Medical Center, 1216 Second St. SW, Rochester, MN 55902. E-mail: hitt.catherine@mayo.edu. Telephone: (507) 284-4422.]

References

1. Hitt CM, et. al. Cost comparison of single daily i.v. doses of ceftriaxone versus continuous infusion of cefotaxime. Am J Health-Syst Pharm 1997; 54:1,614-1,618.

2. Smith CR, et al. Ceftriaxone compared with cefotaxime for serious bacterial infections. J Infect Dis 1989; 160:442-447.

3. Mandell LA, et al. Once daily therapy with ceftriaxone compared with daily multiple dose therapy with cefotaxime for serious bacterial infections: a randomized, double-blind study. J Infect Dis 1989; 160:433-441.