This
study was undertaken to estimate cost differentials between private and public
hospitals for antimicrobial treatment of the admitted paediatiric patients who
were suffering from pneumonia or diarrhoea – the two most common infectious
paediatric problems in Bangladesh. The study was conducted between August 2002
and January 2003 in paediatric wards of two selected medical college
hospitals–one public and the other private. The treatment charts of 107
admitted paediatric patients who received antimicrobial agent(s) for the
treatment of pneumonia (88) or diarrhoea (19) were reviewed daily from the day
of admission of the patients till their discharge from the hospitals. The total
costs of antimicrobial agents per patient were based on the current market
price of these agents. The average cost of antimicrobial course(s) per patient
of pneumonia were for great in private hospital while that of diarrhoea was
higher in public hospital.
Pneumonia and diarrhoea are two major paediatric health problems in
developing countries including Bangladesh.1-3 It has been calculated that the average
individual ingests about 8 microorganisms per minute or 10,000 per day.4 The respiratory and gastro intestinal tracts
are the most common sites for infection by pathogens, often requiring
antimicrobial therapy.
The World Health Organization estimates that up to 40% of the total
health care cost in developing countries may be for drugs.5 Several studies in developing countries such
as India, Thailand and Tanzania estimate that from 24 to 50% of the total
pharmaceutical budget are spent on antimicrobial agents in these countries.6-8
The present study was undertaken to estimate the cost differentials
between private and public hospital for antimicrobial treatment of admitted
paediatric patients suffering from pneumonia and diarrhoea. These two clinical
conditions have been identified as the most common infections diseases of
children in Bangladesh.
This study was conducted in the paediatric wards of two randomly
selected medical college hospitals in Bangladesh - one public and another
private. The data collection procedure was prospective in nature. The treatment
charts of 107 admitted paediatric patients who received antimicrobial agent(s)
for the treatment of pneumonia (88) or diarrhoea (19) were reviewed daily from
the day of admission of the patients till their discharge. There were 18
pneumonia patients in the public and 70 in the private hospital. These figure
were 7 and 12 respectively for the diarrahoea cases. The total cost of
antimicrobial agents per patient was based on the current market price of these
agents.
Estimation
of the cost per patient: CTiAM = å (Unit price of each antimicrobial
agent ´ ‘quantity used per day’ ´ duration of hospital treatment).
The calculated total cost was determined
by summing up costs of all antimicrobial agents given to individual patients.
Results
A total of 157
courses of different antimicrobial agents were used to treat 88 admitted
paediatric patients who were suffering from pneumonia. The five most commonly
used antimicrobial agents were in order of: amoxicillin, gentamicin,
ceftriaxone, cephradine and ceftazdime. Table 1 shows the percentages of
courses of the five most commonly used antimicrobial agents, which accounted
for 80.89% of the total antimicrobial courses. The highest percentage of
amoxicillin (38.46%) was used to treat pneumonia in private hospital and that
of Ceftriaxone (34.78%) in the public hospital. The difference in proportions
of different antimicrobial agents used to treat pneumonia by hospitals was
noticeably different between hospitals.
Table-1: Distribution of antimicrobial agents used
for the treatment of pneumonia (*n = 127)
|
Antimicrobial agents
|
Medical College Hospitals
|
Total No.(%)
|
|
Private No.(%)
|
Public No.(%)
|
|
Amoxicillin
|
7 (30.44)
|
40 (38.46)
|
47 (37.01)
|
|
Gentamicin
|
3 (13.04)
|
40 (38.46)
|
43 (33.86)
|
|
Ceftriaxone
|
8 (34.78)
|
8
(7.69)
|
16 (12.59)
|
|
Cephradine
|
5 (21.74)
|
10
(9.62)
|
15 (11.82)
|
|
Ceftazidime
|
0
(0)
|
6
(5.77)
|
6
(4.72)
|
|
Total
|
23 (100)
|
104 (100)
|
127 (100)
|
*n=number of courses of commonest five
antimicrobial agents.
There were 19
antimicrobial courses with different antimicrobial agents used for the
treatment of 19 admitted paediatric patients who were suffering from diarrhoea
in the two selected medical college hospitals. However, the five most
frequently used antimicrobial agents for the treatment of these patients were
ceftriaxone, cephradine, amoxicillin, metronidazole and ampicillin. Table 2
displays the percentages of courses of the five most commonly used
antimicrobial agents, which accounted for 73.68% of the total antimicrobial
courses used to treat diarrhoea among admitted paediatric patients. The
difference in proportions of antimicrobial courses of different antimicrobial
agents used between hospitals was remarkable. For example, the highest
percentage of ceftriaxone (22.22%) was used to treat diarrhoea in private
hospital and the lowest percentage of this agent (20%) was in public hospital,
while the highest and lowest percentages of metronidazole were 40% and 11.11%
in public and private hospitals respectively.
Table-2: Distribution of antimicrobial agents used
for the treatment of diarrhoea (*n = 14)
|
Antimicrobial agents
|
Medical College Hospitals
|
Total No.(%)
|
|
Private No.(%)
|
Public No.(%)
|
|
Ceftriaxone
|
1 (20.00)
|
2 (22.22)
|
3 (21.43)
|
|
Cephradine
|
1 (20.00)
|
2 (22.22)
|
3 (21.43)
|
|
Amoxicillin
|
1 (20.00)
|
2 (22.22)
|
3 (21.43)
|
|
Metronidazole
|
2 (40.00)
|
1 (11.12)
|
3 (21.43)
|
|
Ampicillin
|
0
(0)
|
2 (22.22)
|
2 (14.28)
|
|
Total
|
5
(100)
|
9
(100)
|
14
(100)
|
*n=number
of courses of five most commonly used antimicrobial agents.
Pneumonia:
The antimicrobial treatment costs were calculated for
a total of 88 admitted paediatric patients in two selected medical college
hospitals who were suffering from pneumonia. The average cost (ACTi) of antimicrobial agents per patient was Taka 218.77
across the hospitals while it was Taka 280.81 and Taka 173.6 in private and
public hospital respectively.
Diarrhoea: The average cost of antimicrobial agents per
patient suffering from diarrhoea was Taka 221.45 across the hospitals while it
was Taka 199.31 and Taka 279.00 in private and public hospital respectively
(Table-3).
Table-3: Average costs of
antimicrobials used for the treatment of admitted paediatiric patients
|
Diseases
|
Hospitals
|
|
Public
|
Private
|
|
Pneumonia
|
|
|
|
Average costs in Taka
|
173.76
|
280.81
|
|
Diarrhoea
|
|
|
|
Average costs in
Taka
|
279.00
|
199.31
|
Table 3 shows that the average costs of
antimicrobial agents used for both pneumonia and diarrhoea varied among
hospitals. The average costs for antimicrobial treatment of pneumonia were far
greater in the private hospital. The average cost of antimicrobial treatment of
diarrhoea was surprisingly higher in the public hospital.
Discussion
It is evident that the difference in the
average cost of antimicrobial agents used for the treatment of pneumonia and
diarrhoea was noticeable across the hospitals. These variations could be a
reflection of the choice of different antimicrobial agents by hospital
physicians for the treatment of similar patients in different hospitals.9-12 The
antimicrobial treatment of the two most common infectious diseases, pneumonia
and diarrhoea, appeared to be higher in the hospitals studied when judged by
comparing with the recommended antimicrobial treatment of these diseases in the
consensus-based Standard Treatment Guidelines available in the country reflecting
the low compliance with the expected norms. Other studies in public and private
health facilities in Bangladesh have also shown similar low compliance with the
specific standard treatment norms.13-17
In both conditions, there was a great
potential for saving hospitals’ and patients’ treatment cost if appropriate
intervention(s) are made and/or strategies improved for antimicrobial
prescribing practices in hospitals of Bangladesh.
The hospital-physicians prescribed newer
varieties of antimicrobial agents in excessive number of courses to treat the
most common infectious diseases: pneumonia and diarrhoea and led to unwarranted
increase in treatment cost.
Acknowledgement
The authors gratefully acknowledge the
financial assistance provided by the WHO to conduct this study.
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