Reviewed Research

REVIEWED RESEARCH

Blood Level Testing in a Community Pharmacy: Consumer Demand and Financial Feasibility By Thomas R. Einarson, J. Lyle Bootman, Lon N. Larson, and William F. McGhan A total of443 subjects completed a pharmacy blood service questionnaire to evaluate the feasibility ofa community pharmacy-based blood level testing service. Subjects stated that they would use such a pharmacy-based service and would pay an average of$11.54 for it. A total of186 patients were tested for potassium or cholesterol levels during the 5 -week study. After using the service, patients expressed satisfaction with the service and reported willingness to pay an average of $14.47 for the service in the future. A financial analysis showed that the blood level testing service would be financially feasible if18 blood level tests were performed each day at a charge of $10 or eight tests at $15. The study indicates that providing a blood level testing service offers pharmacists an opportunity to expand their clinical services to patients.

INTRODUCTION

In recent years, there has been a trend toward the provision of patient-oriented services in pharmacies, including blood glucose screening for diabetes and blood pressure screening. A pilot study of a cholesterol monitoring service in a community pharmacy setting demonstrated its feasibility.1 This larger study of a clinical pharmacy service in a community pharmacy setting that tested serum levels of potassium and cholesterol was conducted to determine public attitudes toward, intention to use, and willingness to pay for the service. To determine the financial feasibil76

ity of implementing such a program, an analysis of costs and revenues was also performed. METHODS

Research was conducted at three locations of a small local chain of pharmacies. Subjects for the study were solicited by posting signs in the pharmacies indicating the availability of a blood testing service that could determine their level of serum cholesterol or potassium, with test results ready in 10 to 15 minutes. Subjects were also informed of the importance of maintaining appropriate serum cholesterol and potassium levels and of

knowing what their own blood levels were. Subjects were then asked to complete a questionnaire that presented statements regarding attitude toward blood level testing in a community pharmacy and intention to use the service, to which subjects indicated their agreement or disagreement by circling the appropriate response on a 5-point Likert scale. Scores ranged from strongly disagree (1) to strongly agree (5). Subjects were also asked to indicate how much they would be willing to pay for such a service by circling an amount ranging from $10 to $25 in increments of $5. In addition, they were asked to indicate which of nine available blood tests they would like to have available in such a service. The 186 subjects who agreed to have a blood test were required to sign a consent form, and blood was taken with a fingerstick, using a sterile disposable lancet. Half of these subjects paid a fee of $5 for the potassium test or $10 for the cholesterol test. Samples were set aside for a few minutes to allow for coagulation, then were centrifuged for 3 minutes on a standard laboratory centrifuge. Serum was withdrawn with a pipette, diluted with water, and analyzed by a reflectance

American Pharmacy, Vol. NS28, No.3, March 1988/188

photometer. All blood drawing and testing were done by a pharmacist. A physician served as consultant to the project as did a licensed clinical testing laboratory. Blood levels were determined by the Ames Seralyzer, a compact (140 mm x 280 mm x 380 mm), portable (10 kg in weight) reflectance photometer. The device uses dry reagent chemistry, producing results equivalent to those :produced by standard methods.!' Tests are done with strips similar to those used to test blood or urine for glucose. Blood level results were reported to the patient as soon as they were available, usually in 10 to 15 minutes. Subjects were then given a posttest questionnaire to measure patient satisfaction with the ser-

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vice, intention to use it again in the future, and willingness to pay. RESULTS AND DISCUSSION

Of 443 subjects completing the pharmacy blood level service questionnaire, 166 (37.5%) were males, and 258 (58.2%) were females; 19 (4.3%) did not report their gender. Ages ranged from 18 to 91 with a mean of 61.0 (SD = 14.26). Thus, patients tended to be older. Questionnaire Results Patients stated that they were in favor of having blood level testing available in a community pharmacy and that they would use the service (see Table 1). They consid-

Pretest Questionnaire Results

Statement 1. I like the idea of being able to have a blood level done in pharmacies. 2. It would be convenient for me to have a blood level done in a pharmacy. 3. If a blood level service were available in a pharmacy, I would use it. 4. I think the information from a blood test would be valuable. 5. I would prefer to leam about my blood level right away without a long wait. 6. I think health insurance should pay for a service like this in a pharmacy.

n

Mean

SO

t*

435

4.4

0.80

37.31

432

4.4

0.78

38.25

426

4.3

0.91

29.82

434

4.6

0.71

46.04

431

4.6

0.70

46.49

425

3.9

1.25

14.62

* All t values are significant at p < 0.001 . NOTE: Score means and standard deviations of questionnaire responses are determined on as-point Likert scale along with single sample t tests contrasting score means from the neutral value of 3.

16NI" Test

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Subject Interest in Blood Level Measurements Available Expressed Interest Number of Subjects

Cholesterol ..... ..... ..... .. .... ...... ....... ... .. .... Potassium ........... .. .. ...... .. ...... .. ........ .. ... Glucose ............. .. ................................ Hemoglobin .......................................... Triglycerides .. .. ........................... .. ......... Uricacid .............................................. Theophylline .. ............... ............ ..... ... ..... Phenytoin................. ...... ...................... Phenobarbital ...................... ..... .. . .. .. .. . .. ..

322 .... ... ....... .. .... .. ... .... ..... .... ·· 314 ........................................ 278 ........ ...... ... ..... .. ................ 251 ... .... ...... ..... ....... ... ... ...... .. . 221 ...... .. ....... .... .. ........... .... .... 183 ....................... ................. 115 ...... ... ......... .... .. ...... .... .... .. 81 ........................................ 79 . .. .. .. .. . .. .. .. .. . .. ... . .. .. .. .. .. . ....

American Pharmacy, Vol. NS28, No.3, March 1988/189

% 72.7 70.1 62.8 56.7 49.9 41 .3 26.0 18.3 17.8

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ered a pharmacy to be a convenient location for them to have a blood test and the results to be valuable to them, and they liked having results available without a long wait. The average amount that subjects said they were willing to pay for the service was $11.54 (SD = $4.55). Table 2 lists available tests associated with drug therapy as well as the number and percentage · of subjects who indicated interest in having access to the tests. Cholesterol was the most often indicated test (72.7%), probably because of its association with coronary artery disease and the resultant emphasis on controlling blood cholesterol levels. A substantial percentage of subjects also indicated interest in potassium and glucose tests (70.1% and 62.8% respectively), reflecting the large number of patients who either take diuretics or are diabetic. Attitudes To Testing A total of 186 subjects had their blood tested. All patients expressed satisfaction with the service (mean = 4.7; SD = 0.46 on a 5-point scale). Tested subjects also confirmed their willingness to be retested in the future if the service were available (score mean = 4.6; SD = 0.63). The amount subjects stated they were willing to pay was $14.47, a significant increase over the amount indicated on the pretest. This suggests that if patients can be induced to try the service, they will value it more. Of three physicians who learned about this service, two reacted enthusiastically, one referring patients for a blood test and the other receiving a blood test himself. The third initially declared strong opposition, but stated the following day that he was neutral on the matter. In any event, a pharmacist engaging in such an enterprise would be wise to win support from local physicians by emphasizing the benefits from such a service, both to patients and to the physician through referrals. Clinical Usefulness Blood level tests have obvious clinical usefulness. First, they screen for the detection of health

n

IbNIII

Cost of Materials for One Year in a Blood Level Testing Service

10 Unit Cost

Item Test strip Microtainers Calibrators Control solutions Pipettte tips Test tubes Lancets Alcohol swabs Bandaids

$50.00/50 $14.95/20 $82.50/6 $70.40/10 $55.00/1000 $16.5811 000 $12.85/1000 $2.00/1 00 $1.00/box

Quantity Required

2,750 2,500 54 50 11,000 5,000 3,000 5,000 10

Total cost of materials

Annual Cost

Number ofTests per Day 20 Annual Quantity Cost Required

5,500 5,000 54 50 21,000 10,000 5,000 10,000 20

$2,750.00 1,868.75 742.50 352.00 605.00 82.90 38.55 100.00 10.00

$5,500.00 3,737.50 742.50 352.00 1,155.00 165.80 64.25 200.00 20.00

30 Quantity Required

8,250 7,500 54 50 31,000 15,000 8,000 15,000 30

Annual Cost

$8,250.00 5,606.25 742 .50 352.00 1,705.00 248.70 102.80 300.00 30.00

$6.549.70

$11.937.05

$17.337.25

$2.62

$2.39

$2.31

Average cost pertest * 250 Working days.

problems, such as high blood cholesterol or hypokalemia in patients taking diuretics. Patients with abnormal findings could be referred to appropriate health care practitioners for further assessment. Second, drug therapy could be monitored on an ongoing basis. Tests are now available for determining theophylline, phenobarbital, and phenytoin levels and are being developed for several other drugs including digoxin. In some jurisdictions, pharmacists are allowed to alter therapy, sometimes using an established protocol. Blood level tests would assist in maintaining optimal drug therapy for ambulatory patients who would have more responsibility for their treatment. In addition, overall costs would be decreased for third party payers.

search. The value of $10 represents the lowest amount that would be charged for a blood test, and the average amount that tested subjects said they were willing to pay for the service was approximately $15. Subjects were informed that the cost they actually paid for potassium level measurements ($5) was lower than actual market value because this was a research study and thus involved no costs for labor. Table 3 presents cost analyses for materials used in a service performing 10, 20, and 30 tests daily. These volumes were chosen because 10 tests per day was the lowest number of tests performed during the research and 30 was the highest. This

Financial Analysis Potential gross revenues were calculated at $10 and $15 per test. Ten tests per day at $10 per test would generate revenue of $25,000 per annum, 20/day would generate $50,000, and 30/day would generate $75,000. At $15 per test, this would rise to $37,500 for 10/day, $75,000 at 20/day, and $112,500 at 30/day. These values were chosen for the analysis because they represented real values encountered in the re-

Equipment

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1M:",.

Cost of Equipment Used to Analyze Blood Levels Cost ($)

Ames Seralyzer Dilution system Test module * Centrifuge

$3,750.00 398.75 55.00 500.00

Total

$4.703.75

* Each test requires its own module (eg, potassium. cholesterol, hemoglobin, theophylline). All modules cost the same.

table shows that as the volume of tests increases, the cost per test decreases, reflecting economies of scale. The Ames Seralyzer used provides quantitative analysis for 14 blood chemistries and three drugs. The device requires serum, necessitating the use of a centrifuge, and dilution of samples, requiring pipettes, test tubes, and other related apparatus. Table 4 lists the total cost of all equipment used. For the financial analysis of expenses, equipment costs were amortized over 36 months. This is reflected in the calculation in Table 5. For the calculation of employee expenses, the salary of a technician was used, since a technician would operate the device. It was assumed that as part of the service, the pharmacist on duty would explain the implications of the blood test to the patient. Table 6 presents financial statements for operation of a blood level testing service in a community pharmacy with a technician performing the tests. As can be seen, such a service would generate a substantial profit at rates of testing achieved during the research study. Financial analyses were based on using a full-time technician to perform tests, with the pharmacist on duty handling any patient ques-

American Pharmacy, Vol. NS28, No.3, March 1988/190

tions regarding blood level test results. However, it could be necessary to pay for additional pharmacist time to consult with patients. Table 7 presents the cost of paying for pharmacist consultations based on an average of 10 minutes per blood level. In such a case, this amount would have to be subtracted from profits or added to losses. The pharmacist is in a unique

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position to provide such a service because of extensive background knowledge of drugs and therapeutics as well as training in laboratory procedures and aseptic technique. In addition, the pharmacist is the most accessible member of the health care team, and regularly consults with both patients and prescribers. Computerized patient record systems used in many phar-

CONCLUSIONS

Expenses Incurred by a Blood Level Testing Service

Expenses

Costs

Technician salary (2,000 hours @ $8/hour) Equipment costs (12/36 x $4,703.75*) Overheadt

$16,000.00 1,567.92 976.85

Total

$18,544.77

* Proportion of total cost each year, assuming amortization over a 36-month (3-year) period. See Table 4 for cost breakdown.

t Based on using 25 square feet of space. Rate taken from Reference 4.

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Financial Statement of Profits (Losses) from a Blood Level Testing Ser-

vice

10

Tests per Day 20

30

Line Item

Profit/CLoss) @ $10rrest

Revenue Cost of materials

$25,000.00 - 6,549.70

$50,000.00 - 11,937.05

$75,000.00 - 17,337.25

18,450.30 - 18,544.77

38,062.95 - 18,544.77

57,662.75 - 18,544.77

($94.47)

$19,518.18

$39,117.98

Gross margin Operating expenses Profit (loss)

Profit/CLoss) @ $15rrest Revenue Cost of materials Gross margin Operating expenses Profit (loss)

IKNIII

l

$37,500.00 - 6,549.70

$75,000.00 - 11,937.05

$112,500.00 - 17,337.25

30,950.30 - 18,544.77

63,062.95 - 18,544.77

95,162.75 - 18,544.77

$12,405.53

$44,518.18

$76,617.98

Cost of Providing a Pharmacist to Counsel Patients on Blood Level Tests

per Day

Tests perYear

Minutes of Counseling

Pharmacist Hours

Cost@ $20/hour

10 20 30

2,500 5,000 7,500

25,000 50,000 75,000

416.7 833.3 1,250.0

$8,333.33 $16,666.67 $25,000.00

Tests

NOTE: Based on 10 minutes consultation time for each blood level tested.

American Pharmacy, Vol. NS28, No.3, March 1988/191

macies allow for ongoing therapeutic monitoring. In some jurisdictions, pharmacists have been granted prescribing privileges, and this could become widespread. Thus, by virtue of knowledge, training, professional and technical skills, and accessibility, the pharmacist is the ideal person to undertake blood level monitoring and interpretation.

This study has described the implementation and evaluation of a blood level testing service in a community pharmacy, established substantial consumer demand for such a service, and determined the financial feasibility of establishing and operating a blood level testing service in a community pharmacy. The study was conducted without advertising the service, which would probably have increased the use of the service. Pharmacists should consider and act upon this patient-oriented clinical pharmacy service as a unique opportunity for expansion into the field of drug therapy monitoring. ®

Thomas R. Einarson, PhD, is assistant professor; faculty of pharmacy, University of Toronto, Ontario, Canada. (This work was part of a dissertation done at the University of Arizona.) J. Lyle Bootman, PhD, is professor and head, department of pharmacy practice, College of Pharmacy, University ofArizona, Tucson; and Lon N. Larson, PhD, is assistant professor and William F. McGhan, PharmD, PhD, is associate professor of the department of pharmacy practice, College of Pharmacy, University of Arizona. REFERENCES 1. T. R. Einarson et ai., Drug Intell Ciin Pharm, 22, 45 (1988). 2. A. Zipp, J Automat Chem, 3, 71, (1981). 3. S.C. Charlton et ai., Ciin Chem, 28, 1857 (1982). 4. C.H. Deiner, Lilly Digest, Eli Lilly and Co., Indianapolis, IN, 1986. 79

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