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Abstract

Developed nations maximize pharmacists, while developing nations underutilize them, especially in operating rooms (ORs), necessitating cost-effectiveness and feedback evaluations. We investigated the impact of pharmacist involvement in operating rooms (OR) at Muhimbili National Hospital. We contrasted a “before era” (BE) without pharmacists to an “after era” (AE) with their presence. We conducted a comparative observational analysis. We examined data from April 1, 2016, to June 30, 2018 (BE), and July 1, 2018, to September 2020 (AE). We interviewed 127 OR Health workers to appreciate pharmacist presence during AE. We performed statistical analysis using Stata 12/IC. We used chi-square and Student’s t-tests for categorical and continuous data, respectively. We set statistical significance at P < .05. In the BE, 32 568 patients underwent surgery, with 31.7% being male, while in the AE, 40 195 patients were operated on, with 40.2% being male. Patient payment method distribution did not significantly differ between eras (P = .68351). The total medication and medical supply costs decreased from TZS 8 631 547 372 in the BE to TZS 6 695 832 350 in the AE. Despite an additional cost of TZS 1 409 400 000 for pharmacist integration, a net cost saving of TZS 526 315 022 was achieved, resulting in an incremental cost-effectiveness ratio (ICER) of TZS 69 007 cost savings per patient served during AE. Health workers satisfaction regarding the inclusion of 40 pharmacists was high, with 98.4% reporting satisfaction. During the AE, 92.9% of OR Health workers were content with pharmacist performance. However, some Health workers did not understand about pharmacist roles in OR due to their limited numbers and suggested prioritizing supply management over direct OR presence. Pharmacists are indispensable members of healthcare teams, particularly in ORs, where their contributions significantly improve patient outcomes and reduce costs. The findings strongly support increased pharmacist deployment in healthcare facilities and further research to explore their impact on healthcare resource utilization.

Keywords

pharmacist hospital patients operating room health workers developing countries satisfaction cost savings

Introduction

Hospital pharmacists play crucial roles in medical teams, encompassing tasks such as medication dispensing, drug-related issue identification, drug information provision, and inventory management.¹ In progressive scenarios, they actively participate in ward rounds to contribute to patient management decisions and offer guidance on dosage and dose adjustments.² Pharmacist interventions, hailed as standard practices in developed nations, are well-documented for both outpatients and inpatients. In developing countries like Tanzania, health systems primarily utilize pharmacists for supply chain management, focusing on medication quantification and dispensing in outpatient and inpatient pharmacies.³ Patient-centered practices are less emphasized, potentially resulting in undetected or underreported medication errors.^4
-6 The scarcity of pharmacist interventions could contribute to the prevalent malpractices and polypharmacy issues in these regions.^5,6

Previous studies have emphasized the crucial role of pharmacists in operating rooms, encompassing tasks such as effective drug management, injectable reconstitution, and offering drug-related information. Additionally, the presence of pharmacists in operating rooms has been shown to alleviate the workload of other health workers, while promoting the rational use of medications and facilitating cost-saving measures.^7,8

Operating rooms invariably include anesthetists responsible for ensuring patient safety during and after the operation in the intensive care unit. Despite their expertise, anesthetists, being human, require vigilant supervision in the mixing and administration of anesthetic drugs to surgical patients, which is where pharmacists play a crucial role. Pharmacists offer oversight for monitoring adverse events in anesthetized patients, thereby enhancing patient safety. Studies, such as those by Chapuis et al highlight the value of integrating pharmacists during anesthetic drug administration and in intensive care units (ICUs) for critically ill patients, correcting drug-related issues, and reducing operation costs.^9,10 In the face of challenges such as delays, pharmacists play a pivotal role in ensuring that patients are adequately prepared preoperatively, cared for during the procedure, and closely monitored postoperatively to optimize medication use and enhance outcomes.^8,11,12

Operating theaters are sites where hospital costs can escalate due to unforeseen circumstances during procedures. Many studies have collectively underlined the significance of pharmacists in the operating room, focusing on cost savings, optimized use of medications and medical supplies, accurate documentation, improved communication within the medical team during procedures, and increased hospital revenues in developed countries.^9,12,13 Comparatively less attention has been paid to the role of pharmacists in operating rooms in developing nations, despite the evident benefits mentioned earlier.^12,14
-16

Although pharmacist-led interventions are frequently depicted as standard practices in the developed world and, to a lesser extent, in middle- and low-income countries, our aim was to underscore the pivotal importance of pharmacists in operating rooms. This encompasses promoting rational use of medications, cultivating robust collaboration with other healthcare teams, reducing costs, and upholding hospital services. Moreover, pharmacists are instrumental in ensuring accurate documentation of patients undergoing surgical procedures.^{2,9,12,13,15,16}

Methods

Study Design

This study utilized a mixed-methods, cross-sectional design, incorporating a retrospective analysis. Specifically, it contrasted 2 periods at Muhimbili National Hospital (MNH): the initial period without pharmacists in operating rooms (ORs), and the subsequent period following pharmacist integration into the operating team from July 1, 2018, to September 30, 2020. This design simultaneously evaluated the quantitative cost savings associated with pharmacist integration and the qualitative health worker perceptions of pharmacist roles, challenges, and benefits in ORs. The study and write up of the manuscript has followed EQUATOR-STROBE- Cross-section checklist guidelines.

Study Procedures

We extracted patient operation numbers from the Hospital Information System (JEEVA) for the Before Era (BE), April 1, 2016, to June 30, 2018, and the After Era (AE), July 1, 2018, to September 30, 2020. We examined patient health financing schemes via JEEVA to assess hospital service sustainability. We collected data on dispensed pharmaceutical costs (medicines and medical supplies) in the operating theater for both BE and AE. We analyzed pharmaceutical values to determine cost savings from pharmacist introduction. We reviewed employment records to determine pharmacist salaries and calculate unbudgeted personnel deployment costs. We documented operating theater numbers and maximum operating hours at MNH from July 1, 2018, to September 30, 2020. We interviewed operating room health workers to gauge their acceptance and satisfaction with pharmacist services. We analyzed continuous data using Student’s t-test{Perezgonzalez, 2015} and categorical data using the chi-square test{Pearson, 1992}, setting significance at P < .05. We estimated the ICER as the ratio of the difference between total AE costs (medicines, medical supplies, and pharmacist deployment) and BE medicine and medical supply costs, divided by the estimated cost of medicines and medical supplies to serve AE patient volume. We conducted all statistical analyses using Stata 12/IC (Stata Corp., USA).

Result

During the period before era (BE), 32 568 patients underwent surgery. Of these, 10 317 (31.7%) were male. In the after era (AE), 40 195 patients underwent operations, with 16 152 (40.2%) being male. Our findings indicated a significant increase in male (BE = 31.7%; AE = 40.2%, P < .0001). There was no statistically significant difference in the distribution of operated patients based on payment method (cost-sharing, private, or NHIF) between the 2 eras (P = .68351). In BE, patients who underwent surgery were categorized as follows: cost sharing 44.6%, private 8.5%, and NHIF 46.9%, whereas in AE, the distribution was 42.2%, 9.8%, and 48.0%, respectively.

In terms of medicines and medical supplies, the average operating cost per patient was significantly different between BE (TZS 265 031.55) and AE (TZS 166 583.71; t-test, P < .0001). The total cost of pharmaceuticals dispensed was TZS 8 631 547 372 in BE and TZS 6 695 832 350 in AE, saving approximately TZS 1 935 715 021 (28.9%) without accounting for pharmacist salaries and on-call allowances. Even with Pharmacists deployment costs included, the average cost in the after era (AE) remained significantly lower (TZS 20 648 per patient) compared to the before era (BE; TZS 265 031 per patient), with P < .05 (Table 1).

Table 1.

Description of the Cost Incurred in the BE and AE.

Descriptions		Before Era (BE)	After Era (AE)
Patients (n)		32 568	40 195
Sex (Male)		10 317	16 152
Average cost of medicines & medical supplies used per patient (TZS) without pharmacists costs		265 032	166 584
Average cost of medicines & medical supplies used per patient (TZS) with pharmacists costs		265 032	201 648
Cost used	(Medicines & Medical supplies)	8 631 547 373	6 695 832 351
	40 Pharmacists (TZS 1 215 000 per month)	NA	1 312 200 000
	Pharmacists (on-call allowances TZS 20 000 per day)	NA	97 200 000
Total costs		8 631 855 289	8 105 232 351
Cost saved in 27 months			526 315 022
Cost saved per month			19 493 149
Anticipated annual saving			233 917 787

The ICER = (CA − CB)/(EA − EB); Whereby CA = Total costs of pharmaceuticals and pharmacist services during the After Era (AE); CB = Total costs of pharmaceuticals during the Before Era (BE); EA = Number of patients served during AE; EB = Number of patients served during BE. ICER = (8 105 232 351 − 8 631 855 289 )/(40 195 − 32 568) = −69 007.

During AE, 40 pharmacists were deployed in 18 operating rooms at the MNH for a maximum of 12 h. At times, the 2 pharmacists handled the 3 operating rooms. The cost of deploying pharmacists during AE was TZS 1 409 400 000 (salary being TZS 1 312 200 000 and on-call allowances being TZS 97 200 000), saving about TZS 19 493 149 monthly and TZS 233 917 788 annually (Table 1).

In AE, the hospital would have incurred TZS 10 652 943 152 patients service costs without pharmacist deployment saving about TZS 2 021 413 868 with incremental cost effectiveness ratio of 69 047.

The Incremental cost effectiveness ratio (ICER) was estimated to be minus 69 047; that means about TZS 69 047 cost saved to every patients served during intervention era (AE).

An interview with 127 health workers in operating theaters revealed that pharmacists were generally accepted by other health workers. Most of the health workers (98.4%) acknowledged the role of pharmacists, although 2 doctors had reservations about their presence, emphasizing the importance of restricting themselves to supply and product quality, rather than staying in the operating rooms. Overall, 92.9% of the health workers were satisfied with the performance of pharmacists in operating rooms. Some health workers suggested increasing the number of pharmacists to ensure 1 in each room, and highlighted the impact of pharmaceutical shortages on pharmacist performance. The results showed no significant differences in acceptance and service satisfaction among doctors, nurses, and health attendants regarding pharmacists’ integration into the medical team in operating theaters (acceptance, P = .622; satisfaction, P = .639).

Discussion

This study introduces a novel approach to healthcare delivery in sub-Saharan Africa by examining the integration of pharmacists into operating room (OR) settings on a full-time basis. Pharmacists were responsible for ensuring an uninterrupted supply of medications and medical supplies, managing inventories, and calculating medication costs. Their collaborative role with surgical teams in assessing patient needs and maintaining anesthetic equipment enhances the overall efficiency of the OR.

Our study discovered a noteworthy increase in the proportion of males utilizing facilities at Muhimbili National Hospital, escalating from 31.7% to 40.2%. This contradicts the trend observed in many studies, which often depicts a scenario of men underutilizing health facilities. Notably, the government’s augmented healthcare expenditure since 2016 has led to the acquisition of advanced diagnostic and laboratory equipment along with a boost in the budget allocated for medications and medical supplies.¹⁷ These developments have fostered an environment conducive for men to access public health care facilities. Factors such as the refurbishment of private wards to meet presidential standards, upgraded equipment in operating rooms, the availability of 2 MRIs, digital X-rays, and other enhancements, along with the increased expenditure on pharmaceuticals, rising from less than 700 million (2016) to over 2 billion (2020) per month, have contributed to this positive shift.¹⁷

There was a statistically significant difference in the number of surgeries performed before (BE) and after (AE) the eras (P < .0001). This indicates that enhanced infrastructure and skilled medical personnel in AE influenced the utilization of public health facilities.¹⁸ However, the extent of this increase was unexpectedly low compared to the allocated budget. This discrepancy suggests that the COVID-19 pandemic affected the availability of supplies, resulting in a decline in the performance of health facilities starting in March 2020. A similar trend was observed by Chapui et al in France in 2022, where a reduction in surgical activities was reported due to a significant portion of supplies being directed toward critically ill COVID-19 patients.¹⁹

Despite the absence of a statistically significant difference in the distribution of patients undergoing operations based on payment method across the 2 time periods, there were notable slight fluctuations in the proportions of patients classified under cost-sharing, private, and NHIF categories. These changes in proportions could potentially be linked to shifts in healthcare policies and enhancements in services. Notably, the Tanzanian government mandated that all public servants utilize NHIF, while a few private insurance companies opted to work with the MNH because of their positive experiences with the services offered.²⁰ A slight decrease in the number of cost-sharing patients using the MNH may suggest an improvement in lower-level hospitals, reducing the need for patients to seek common or unfinished surgeries at tertiary hospitals.^17,20

Our results indicate that the average operating cost of medicines and medical supplies per patient was TZS 265 031.55 in before era (BE) and TZS 166 583.71 in after era (AE), with a statistically significant difference (P < .0001). This suggests that integrating pharmacists into operating rooms has led to more rational use of pharmaceuticals, resulting in reduced surgery-related costs. Similar observations regarding the benefits of pharmacists’ involvement in daily healthcare services have been reported by other scholars.^21
-23 Our findings indicated an incremental cost-effectiveness ratio (ICER) of TZS 69 047 cost savings per patient served during AE, which aligns with reports from other authors on pharmacists’ participation in various healthcare intervention programs.^{9,12,13,21
-25}

An area of concern for many human resource experts is the escalating wage bill within their organizations, particularly when productivity levels remain constant. In our study, we deployed a workforce of approximately 40 individuals, specifically, pharmacists. The deployment of pharmacists during the after era (AE) incurred a cost of TZS 1 409 400 000, leading to monthly and annual savings of TZS 19 493 149 and TZS 233 917 787, respectively. This demonstrates that integrating pharmacists into the operating room setting is both productive and worth implementing by employers. The pharmaceutical management roles of pharmacists are well-established in prior research. In our study, their responsibilities included maintaining proper inventory, ensuring timely supply, and participating in pre-operative patient preparations to determine the necessary type and quantity of pharmaceuticals. This finding is consistent with previous studies that have highlighted similar advantages resulting from pharmacists’ engagement in various roles across the healthcare sector.^{12,13,15,16,25
-28}

Introducing pharmacists into the operating room team resulted in unexpectedly high acceptance among medical personnel (98.4%). This finding suggests widespread recognition and valuation of pharmacists’ contributions to patient care and the overall healthcare team.²⁹ Our study aligns with previous research demonstrating similar positive attitudes toward pharmacist integration.^25,29
-31

Pharmacists integrated into the operating room (OR) during AE were satisfied with the Health workers (surgeons, anesthetists and nurses; 92.9%). The Pharmacists roles encompassed patient list management, anesthetic medication preparation, and ensuring medication and medical supply availability in the OR. While some Health workers members advocated for increased pharmacist numbers, overall sentiment highlighted the positive impact of pharmacists on OR efficiency. Pharmacists were instrumental in addressing supply shortages, reducing the workload for surgeons, anesthetists and nurses, and contributing to a smoother OR operation. The health workers in question were performing pharmacist duties in addition to their primary responsibilities, creating an extra burden, especially considering that a dedicated profession (pharmacists) exists for these roles. Our study found no statistically significant differences in other health workers’ satisfaction with pharmacist intervention, consistent with prior research on health worker perceptions of pharmacist performance.^25,26,30

Conclusion

Pharmacists are indispensable members of healthcare teams, with their contributions to operating rooms proving especially valuable. Strong support from other healthcare professionals underscores their essential role in fostering collaboration and improving patient outcomes. To optimize healthcare resource utilization, we recommend increased deployment of pharmacists in healthcare facilities and further research exploring the impact of pharmacist involvement.

Study Limitation and Recommendations

We acknowledge that this study relied on a 27-month observation period, which limited our ability to assess long-term sustainability and introduced uncertainty through linear extrapolation. To improve future research, we recommend extending the observation period. We also recognize that we did not clearly define the scope of cost savings including supply chains costs, availability of pharmaceuticals and inflation, therefore hindering replicability and generalizability. We suggest future studies explicitly define these scopes. Further, we failed to consider uncertainties like pharmacist salary variability, drug price fluctuations, and surgical volume changes. We recommend incorporating sensitivity analysis to address these uncertainties. We focused solely on cost savings, neglecting clinical outcome metrics. We recommend that future research include medication error rates, patient mortality, and morbidity to evaluate overall value and effectiveness. We did not provide a detailed cost category breakdown. We recommend analyzing salary versus error-related savings to identify key drivers. Finally, we did not perform sensitivity analyses to model uncertainties or validate assumptions. We recommend future research perform these analyses to strengthen conclusions.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251343776 – Supplemental material for Cost Saving and Health Workers Perceptions of Pharmacist Integration in Operating Rooms: A Mixed-Methods Cross-Section Study

Supplemental material, sj-docx-1-inq-10.1177_00469580251343776 for Cost Saving and Health Workers Perceptions of Pharmacist Integration in Operating Rooms: A Mixed-Methods Cross-Section Study by Deus Buma, Solobi Ngasa and Arnold Ndesangia in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors wish to express their deepest gratitude to the pharmacy staff, other healthcare professionals, and hospital administrations for their invaluable contribution to the successful implementation of these initiatives. Their collective dedication, expertise, and unwavering support were instrumental in achieving their objectives.

ORCID iD

Deus Buma

Ethical Considerations

The Muhimbili National Hospital Institutional Review Board (MNH-IRB) granted ethical clearance for the original proposal titled, “The Effect of Pharmacists Interventions on Medication Adherence, Clinical Outcome and Cost Effectiveness for Hospitalized Patients at Muhimbili National Hospital, Tanzania,” referenced as MNH/IRB/I/2020/005, dated March 16, 2020. Consent was obtained from healthcare workers in the theaters prior to the interview in accordance with Good Clinical Practice, as outlined in the Declaration of Helsinki.

Author Contributions

Deus Buma conceived the study, developed the proposal, executed the research, collected and analyzed the data, drafted the manuscript, verified its accuracy, and approved its final form. Solobi Ngasa contributed to proposal development, research implementation, and manuscript writing, and verified and approved the final manuscript. Arnold Ndesangia participated in the research implementation and manuscript writing and verified and approved the final manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Research data supporting this publication are available from the hospital information system referred as JEEVA.

Supplemental Material

Supplemental material for this article is available online.

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