THE CLINICAL PATHWAY AND COST OF TREATMENT ON METHADONE MAINTENANCE IN RUMAH SAKIT KETERGANTUNGAN OBAT JAKARTA (DRUG DEPENDENCE HOSPITAL JAKARTA) Ronnie Rivany Lecturer, University of Indonesia Email: ronnie_rivany@yahoo.com Abstract The drug abuse results in increasing HIV/AIDS prevalence among drug users using injection. Methadone Maintenance Treatment Program (MMTP) is an alternative way for the treatment that at present has not yet equipped with 1) clinical pathway and 2) cost of treatment as standard average cost of health care services. The purpose of this study was to design and applied clinical pathway and cost of treatment of MMTP along with its casemix in Drug Dependence Hospital Jakarta (DDHJ). The method used INA-DRG (Rivany, 2008) which is based on evidence from medical record and focus group discussion between medical and non medical staff, related professional organization and hospital management. Based on numbers and types of treatment utilization in clinical pathway, cost of treatment was done using activity based costing with simple distribution method. The result showed that the length of stay for MMTP was 338 days, with casemix that consist of TBC, Hepatitis, HIV/AIDS and its combination. Treatment cost for MMTP was IDR 66.024.016 with the casemix for complicating disease ranging from IDR 70.156.705 to IDR 211.863.018 and IDR 84.875.621 to IDR 226.988.354 for casemix with combination of complicating and incurring diseases. Key Words : INA-DRG s, Diagnosis Related Group, Clinical Pathway & Cost Of Treatment *) Health Policy and Administration Department, Faculty of Public Health, University of Indonesia, 1 st floor - F Building, UI Campuss, Depok 16424, Indonesia (email:ronnie rivany@yahoo.com) Introduction The effect of the drug abuse is very complex covering the problems in legal, social, economic and health. Based on the BNN (National Narcotic Organization) and Puslikes UI (The Center of Health Research University of Indonesia) 2005, it was revealed that the number of drug abuse prevalence in Indonesia was 1,5% - 1,9% (3.5 4,5 millions) of the Indonesian population. Drug abuse in High School and University students in 2003 was 3.9%. The effect of social economy caused by the misuse and the illegal circulation of drugs in Indonesia was Rp. 23.6 trillions. The cost consisted of the social cost of Rp. 5.14 trillions and the economical cost of Rp. 18.48 trillions, and around Rp. 11.36 trillions as the cost of drugs purchase (1). It was assumed that in 2005 around 38.6 millions of people suffered from HIV in the world. At least around 4.1 millions of people suffered new infection and around 2.8 millions died because of AIDS. In November 2006 Department of Health showed the fact that the drug users using injections in Indonesia who were infected by HIV was very high that was 46%. Therefore, the program for the control of the bad effects from the transfer by drug injecting users (harm reduction) was badly needed. Based on the Decision by the Ministry of Health of the Republic of Indonesia No. 464/MENKES/SK/VII/2006 in regards to the Hospital Allocation and the Trial Satelit on Methadone Therapy and the Guideline on Methadone Maintenance Therapy, it was decided that Drug Dependence Hospital Jakarta (DDHJ, Rumah Sakit Ketergantungan Obat Jakarta) as the Trial Hospital for the service of Methadone Maintenance Therapy. Methadone Maintenance Therapy Program is the substitute therapy to reduce the bad effects of HIV/AIDS transfer trough needle injections (2). Methadone Maintenance Therapy Program consists of three (3) steps covering induction, 42
stabilization and maintenance phases. In the Induction phase the severity on the dependency and the consumption of other sedative drugs must be watched. The maximum dosage that can be given in the Induction phase is 30 mg/d and the patient s condition must be monitored for the first 4 hours after it is given to see the any rejection or intoxication signs. The dosage can be increased every 4 days with the maximum dosage of 40 mg (2.3) in the first week. In United States, the programs for Methadone Maintenance Therapy must have the FDA agreement and license and also the agreement from the related country. The aim of this program is to stop the drug dependence completely. To join this program, it needs a proof that the patient has drug dependence of morphine type and has suffered at least 2 years. Methadone is dl-4.4 difenyl-6-dimetylamino-3-heptanon which is available in 2 forms. L-methadone is analgesic with the strength 8-50 times more than d-methadone. The analgesic effect in 7,5-10 mg methadone is equal to 10mg morphine. The side effect occurred more in oral administration compared with parenteral administration. The main danger in using suitable dosage of methadone is the decrease of pulmonal ventilation. The choice of the opiat as the analgesic depends on the patients acceptance, analgesic effectivity, pharmacokinetic, pharmacodynamic and the side effect profile. Methadone is classified as opioid matter which pharmacologically used to relieve the pain where the methadone outcome reaches 30-60 minutes with its half time 12-24 hours. Methadone is synthetically manufactured and can be administered intramuscularly and per orally (4.5). ICD X-WHO (6) and Australian Refined DRG put the disease into several Major Diagnostic Category (MDC) which is divided into 3 categories which are surgery, other, and medical, that further can be classified into several Diagnosis Related Group s (7). DRG s is a way to identify patients who have needs on the same sources in the hospital and it is further grouped into a group that is easily managed technically and related also to the casemix incurred (7.8.9.10). Specifically for this drug/opioid (Opioid Drug Dependence Disorders), complied with AR- DRG Opioid Dependence included in MDC 20 with DRG V.63A and V.63B classification. Opioid dependence does not cause the patient to be hospitalized, but because of the incurring and/or complicating diseases such as TBC- Hepatitis and HIV/AIDS, the patient must be hospitalized. Clinical pathway is a concept of complete services that covered every step given to the patient based on the medical services, the standards of nurse care and the standard of health team services. The service based on the proof with a result that can be measured and in a certain period during hospitalization. Clinical pathway is an audit tool for the management and the clinical condition, starting from the patient s registration and ending when the patient is recovered and discharged (8,9,10,11). Clinical pathway combine the plan for health service and nurse care with other therapies such as nutrients, physiotherapy, and mental state. Clinical pathway is not a standard for the service or the substitute for clinical assessment or doctor s orders, but as an integrated document to simplify the patient s care process and to make the clinical and financial services effective by combining the team and clinical approach. The problem in Indonesia is that the control of HIV/AIDS spread on drug users using injections is agreed to be treated with Methadone Maintenance Therapy. However until today there is no clinical pathway that can be used as a reference or quality control in servicing. Besides that, it is the fact that there is no calculation on the cost of treatment from Methadone Maintenance in the Technical Application Unit (TAU/UPT) in Health Ministry environment. Survey based on INA- DRG (12) aimed to obtain clinical pathway and the calculation of cost of treatment on Methadone Maintenance in UPT/TAU Hospital under Indonesian Ministry of Health. Material and Method The population in this survey were all patients with main diagnose when discharged, whereas the samples for all patients with the Opioid Dependence Disorders (ODD) with main diagnose when discharged and Methadone Maintenance chosen as medical treatment within the last year in the Hospital. The criteria include : 1) Discharged patients who already recovered and considered had completed their medical treatment with main diagnose/entered and 43
discharged at the same time, and 2) The patients had complete medical record status. Secondary data taken from the inpatient medical record within the last 1 year, whereas primary data was on the interview, observation and Focus Group Discussion (FGD) with the Professional Association / Perhimpunan Dokter Spesialis Kesehatan Jiwa (PDSKJ/The Association for the Mental Health Specialist) with the doctor, nurse and related hospital management whereas the activity results data was taken from the Hospital s latest year profile. The cost on medical treatment was calculated based on clinical pathway by using activity based costing method for its direct cost and simple distribution method for its indirect cost. The cost level in this survey was the degree of the cost which happened because of the degree of severity (7) which showed the comparison between the Methadone Maintenance Therapy in Opioid drug dependent patients group and the group of opioid drug dependent patients with the complicating and incurring diseases (casemix). Result Patient s characteristic Around 92.05% of patient who underwent Methadone Maintenance Therapy were males. Two major groups were between the age more than 30 y.o (>30 y.o) and a group with the age 25 30 y.o (25-30 y.o). Around 67.04% of these patients were already underwent Methadone Maintenance Therapy more than 6 months and around 32.95% just underwent the therapy less than 6 months (Table 1). Table 1. Gender characteristic, age, and the therapy duration on the Methadone Maintenance Therapy patient at RSKO Jakarta in 2009 (n=88) Characteristic Category Total number Percentage Sex Men 81 92.50 Women 7 7.95 Age < 25 y.o 10 11.4 25-30 y.o 38 43.2 > 30 y.o 40 45.5 Therapy duration <= 6 month 29 32.95 > 6 month 59 67.05 Total 88 100.0 The degree of severity in the group of patients with drug/opioid dependence showed a mix case which was called casemix. From the survey result, a number types of diseases suffered by the methadone maintenance therapy patients in this casemix such as TBC, Hepatitis and HIV/AIDS. Around 59 (67.05%) methadone maintenance therapy patients did not have complicating and incurring diseases or only suffered opioid dependence problems and further called Pure Methadone Maintenance patients. Casemix which showed the patient distribution frequency with HIV/AIDS was 19.32%, patient with TBC was 1.14% and patient with Hepatitis was 2.27%. Patients who suffered from the complicating and incurring diseases between TBC and HIV/AIDS was 7.95% and patient with complicating and incurring diseases between Hepatitis and HIV/AIDS was 2.27% (Table 2). Table 2. Type of complicating and incurring in Methadone Maintenance Therapy patients at RSKO Jakarta in 2009. Patient Status Frequency Percentage Opioid addicted (ODD) 59 67.05 ODD + TBC 1 1.14 ODD + Hepatitis 2 2.27 44
ODD + HIV/Aids 17 19.32 ODD + TBC + HIV/Aids 7 7.95 ODD + Hepatitis + HIV/Aids 2 2.27 Total 88 100 Note : Opioid drug dependence = opioid dependence disorder Clinical Pathway Based on the recapitulation on the treatment and utilization obtained from the patients medical record with the opioid dependence, the clinical pathway draft was done by calculating the average score on the treatment, and then mean score or median was calculated based on the distribution. The average score obtained will be used as basic material to perform FGD. Based on the FGD result which was performed by the Perhimpunan Dokter Spesialis Kesehatan Jiwa (PDSKJ, The Association of Mental Health Specialists), dokter Poli Terapi Rumatan Metadon (Methadone Maintenance Therapy polyclinic doctors),doctor-other related non medical and hospital management staffs, the clinical pathway for the opioid dependence patient group and opioid dependence patients group and its casemix was obtained. The finalization on the total number and the type of the utilization treatment was based on the agreed clinical pathway (Table 3). Table 3. The total number and treatment type on the clinical pathway of pure Methadone Maintenance Therapy with complicating and incurring patients, at RSKO in 2009. NO ACTIVITY UTILIZATION 1 2 3 4 5 6 I REGISTRATION 1. Outpatient policlinic 4 10 52 16 16 52 2. Methadone policlinic 334 334 334 334 334 334 II DIAGNOSE (Napza policlinic) 1. Psychosocial data 1 1 1 1 1 1 2. Medical chek up 4 10 52 16 16 52 3. Starting registrating data 1 1 1 1 1 1 4. The drug user historical data and his/her treatment 1 1 1 1 1 1 5. Major diagnostic application 1 2 2 2 1 3 6. Commitment 1 7 52 16 16 52 III THERAPY 1. Induction phase 4 4 4 4 4 4 2. Stabilization phase 11 11 11 11 11 11 3. Maintenance phase 323 323 323 323 323 323 Counselling Group 12 12 12 12 12 12 4. Supporting examination 1. Routine test a. Routine blood test 3 3 3 3 3 3 b. SGPT 3 3 3 3 3 3 c. SGOT 3 3 3 3 3 3 d. VCT 2 2 2 2 2 2 e. Napza Urinalysis 5 5 5 5 5 5 2. Additional test Test Anti HIV 1 1 1 1 1 1 CD4 1 1 1 BTA 2 2 Thorax photo 3 3 SGOT 3 3 45
SGPT 3 3 HbsAg 1 1 HbeAg 1 1 USG 1 1 HBV-DNA 1 1 5. Psychology 1 1 1 1 1 1 6. Drug administration Main drug (Methadone) 20 mg 4 4 4 4 4 4 100 mg 11 11 11 11 11 11 60 mg 323 323 323 323 323 323 Additional drug standard 1 1 1 1 1 1 TBC 1 1 Hepatitis 1 1 ARV 1 1 1 Note : 1 = The opioid drug dependence patients group (ODD), 2 = ODD + TBC, 3 = ODD + Hepatitis, 4 = ODD + HIV/AIDS, 5 = ODD + TBC + HIV/AIDS, 6 = ODD + Hepatitis + HIV/AIDS The clinical pathway which was agreed in the FGD result e.g. : 1) Methadone Maintenance Therapy is for outpatients therapy; 2)The opioid drug dependence does not cause the patient to be hospitalized but because of the casemix with complicating and incurring diseases the patients must be hospitalized; 3)The presence of complicating and incurring diseases as a casemix are TBC, Hepatitis and HIV/AIDS with different kinds of levels. Specifically, the steps in the clinical pathway of Methadone Maintenance are : 1) Registration, to show the number of visits for the patients group that actually differ/same in the degree of severity with opioid drug dependence patients group, and the patients group with opioid drug dependence with casemix, 2) Diagnostic application performed in Napza polyclinic where the utilization on the medical check up will also vary according to their degree of severity along with their commitment and consistency for their treatment, 3) The therapy phases include : (a) Induction phase for 4 (four) days, (b) Stabilization phase for 11 (eleven) days and (c) Maintenance phase including group counseling of minimal 10 times within 10 months; (d) The supporting examination for Methadone Maintenance including routine blood test, SGPT, SGOT, Voluntary Counseling Test (VCT), Urinalysis. For the additional examination will be given according to their casemix, such as anti HIV test given once to all the patients group, CD4 given once to the patients group with HIV casemix and twice (2x) for BTA examinations, 3x (three times) for thorax photos, 3x (three times) for SGOT- SGPT examinations for the patient group with TBC casemix. For the patients group with Hepatitis casemix the tests that must be carried out minimum of 1x (once) : HBsAg, HBeAg, USG and HBV DNA; (e) Psychological examination for each group of patients ; (f) The main drug (Methadone) administration starting with the dosage 20 mg for 4 times, dosage 100mg for 11 (eleven) times and dosage 60 mg within 323 days. For the additional drug administration which is symptomatic should be given according to the needs for additional drug such as for TBC, Hepatitis and Anti Retro Viral which is suitable to each patients group. Specifically for the number and type of utilization for the medical service given, FGD agreed that there is linear correlation from each clinical pathway phases, whereby with the present of casemix that cause the degree of severity, starting from number 1 that is opioid drug dependence patients groups, up to number 6 for the opioid drug dependence group with TBC, HIV/AIDS and Hepatitis casemix. Cost Of Treatment The amount of cost of treatment based on the clinical pathway can be calculated by multiplying the unit cost with the utilization in each clinical pathway phases. The cost of treatment and cost level between methadone maintenance patients with casemix is shown in table 4. 46
Table 4. Cost of treatment and cost level on methadone maintenance patient and their casemix Complicating and incurring diseases COT CL Opioid Addiction (ODD) 76.128.408 1 ODD + TBC 82.931.721 1.09 ODD + Hepatitis 233.666.137 3.07 ODD + HIV/Aids 92.560.037 1.22 ODD + TBC + HIV/Aids 95.270298 1.25 ODD + Hepatitis + HIV/Aids 246.962.625 3.24 Note : COT = Cost Of Treatment, CL = Cost Level By assuming than the amount the cost of treatment in ODD group is =1, the methadone maintenance therapy patients group with the complicating Hepatitis (CL = 3.07) and its complication (CL = 3.24) a very high cost of treatment is needed than with other complicating diseases. Disscussion Patients who underwent methadone therapy at RSKO (DDHJ) were mostly males that is 92%. The surveys which was performed by BNN and Puslitkes-UI in 2005, showed that the majority (79%) of drug users using injections were males. The high prevalence in male drug users also triggered the high prevalence of HIV/AIDS(1). Based on the AIDS Control Commission (KPA) up to June 2007 the data obtained was that the ratio in living person with HIV (ODA) in males was 4 x more than in female. From the survey s result it was obvious that males have higher risk to contract HIV from the injection more than females. Looking at the above statement, the program for using condom for the drugs addicts suffering from HIV/AIDS and the program for free needle offer, should be emphasized more to males drug addict than to females. This will reduce the HIV/AIDS transfered both by sexual contact or by sharing needle for injection. The age average of the methadone maintenance patients cases is 30,2 years, and the minimum age is 21 y.o and maximum age is 49 y.o. The period from age 21 y.o up to 49 y.o is the productive age period, where they are potential workers. The addiction to injecting drugs has caused them unable to work optimally due to the heroin effect causing the addiction. The clinical pathway for the methadone maintenance therapy obtained, based on the recapitulation of the average score and the type of medical treatment in patients medical record (12). That average score was used as basic discussion materials among the specialist to reach an agreement in clinical pathway where these discussion result as the basic for cost of treatments calculation. Specifically for the decision on methadone maintenance it was agreed that this therapy is for the outpatients and not for the inpatients where it was similar to the Australian Refined- Diagnosis Related Groups (AR-DRG) that include the disease group with opioid drug dependence patients into Major Diagnostic Categories no.20 (MDC 20) group with the Diagnosis Related Group no. V63A and V63B which was the disease with opioid dependence (7). The cost of treatments were calculated by multiplying clinical pathway in each phase with the unit cost of each phase, the sum result was the whole cost of treatment based on the clinical pathway (13,14). The utilization difference between one disease and other complicating diseases is caused by the fact that the patients must have laboratory tests to confirm on the diagnosis of the diseases they suffer and to see their physical condition in general because of the therapy combination effect. Besides that the patient must be given the medication which was for the disease she/he was suffering. The utility increase in health facility caused the increase in cost of treatments (17). In this case the cost of treatment was the expense from the hospital aspect which was needed for the pure methadone maintenance therapy for 338 days which is Rp. 47
76.128.408. For the methadone maintenance therapy with complicating TBC was Rp. 82.931.721 in methadone with complicating hepatitis which was Rp. 233.666.137 with the highest cost component that was the cost for extra medicine. The cost of treatment for the methadone maintenance therapy patients with complicating HIV/AIDS was Rp. 92.560.037 whereas the methadone maintenance therapy with complicating and incurring TBC and HIV/AIDS was Rp. 95.270.298 with the highest cost component was the maintenance phase cost. Finally, the amount of the cost for the methadone maintenance patient with complicating Hepatitis disease and HIV/AIDS which was Rp. 246.962.625, with the highest cost component was the cost for the additional medicines. The cost for the treatment for chronic and long life diseases was adjusted to the length of the methadone maintenance therapy that was 338 days. Based on the cost level between one and other diseases, the cost of treatments for the methadone maintenance therapy with the complicating diseases TBC and HIV/AIDS or both only causing the cost increase 1.6 and 1.25 with 1.29 of the cost for Pure Methadone Therapy. This was caused by the additional cost of medicine and counseling which was not too high. It differed from the cost of treatment with the complicating Hepatitis or complication of Hepatitis, the medical cost became 3.07 and 3.24 from the medical cost of pure methadone maintenance therapy. The use of interferon as the therapy for hepatitis must be given for one year so that the patient could be completely recovered from hepatitis. Conclusion Based on the survey results of the clinical pathway and cost of treatment in methadone maintenance patient at RSKO Jakarta (DDHJ), it can be concluded that the casemix or complicating and incurring diseases are known as TBC, Hepatitis and HIV/AIDS and the combination of both. From the FGD result it is also agreed that methadone maintenance therapy is inpatients therapy and needs therapy time 338 days with the cost of treatment in the ODD group which is Rp. 66.024.016 with CL = 1, the highest cost of treatment of Rp. 246.962.625 resulted because the patient is given interferon. Suggestion From the aspect in policy it needs to be suggested to review Kepmenkes NO 464/Menkes/SK/VII/2006 about the length of therapy in methadone maintenance patient because of the survey result showed that the length of maintenance therapy is in fact more than 6 month and up to 338 days or 10 (ten) months. From the operational technical aspect in Rumah Sakit Ketergantungan Obat Jakarta (RSKO/DDHJ), the activity and the efficiency must be noticed by looking into the output and the cost structure related to the clinical pathway phases and the methadone maintenance cost of treatment, where as a whole further program in maintenance therapy is needed. From the INA-DRG development aspect, the adjustment from MDC.20 with the Diagnosis Related Group no V63A and V63B must be thought of, because it is found that there are casemix as with TBC, Hepatitis and HIV/AIDS and the combination of both which can cause a degree of severity. References 1. Puslitkes UI, Studi Biaya Sosial dan Ekonomi Penyalahgunaan Narkoba, Jakarta 2005. 2. Departemen Kesehatan Republik Indonesia, Keputusan Menteri Kesehatan Republik Indonesia nomor 49/MENKES/SK/VII/2006, tentang penetapan rumah sakit dan Satelit uji coba pelayanan terapi rumatan metadon serta pedoman program terapi rumatan metadon, 2006 3. Pedoman Pelaksanaan Program Terapi Rumatan Metadon, Departemen Kesehatan RI, 2007. 4. Kusnady, Andy A, 2007, Rumatan Metadon di Indonesia, http://satudunia 5. net/?=content/terapi-rumatanmetadon-di-indonesia. 6. World Health Organization, Regional Office for South East Asia, Operational guidelines for the management of opioid dependence in the South East Asia Region, 2008. 7. World Health Organization, International Statistical of Diseases and Related Health problems -10 th Revision, 2 nd Ed, Geneva, 2004. 8. Australian Defined Diagnosis Related Group, Definition Manual, Australian 48
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