In this study, we evaluated the appropriateness of using albumin in accordance with UpToDate and checked its compliance with this protocol. We tried to perform a drug utilization evaluation (DUE) on albumin, which is mostly performed in critical patients and thus has a significant effect on patient mortality. We filled in the required information for each patient based on her file in Shahid Rahimi Hospital and by comparing each one with UpToDate, we reported the rationality of albumin administration, the additional costs imposed on the person, the hospital and the government, etc.

A statistical survey was conducted in Shahid Rahimi Hospital, Khorramabad, Iran, from April 1 to March 2017. Albumin administration was evaluated for randomly selected patients who received albumin in different departments. If the use of albumin changes during hospitalization, the patient should be included in the study more than once. The main source for retrieved information was pharmacy drug files, patient files (including laboratory information) and nursing files. Age, sex, weight, section, albumin level, symptoms and final dose were recorded for each patient. Contraindications for administration of albumin or any precautions in its use were also investigated.

The data were analyzed using SPSS16 and Excel software, independent T-test and chi-square were used to compare quantitative and qualitative variables. Data were expressed as Mean ± SD or percentage. A P value of less than 0.05 is considered a statistically significant difference.

Results

The present study was designed and conducted to evaluate the consumption and appropriateness of albumin administration in patients admitted to Shahid Rahimi Hospital in Khorramabad city in Lorestan province. This study examined 271 medical records, including 160 men (59.0%) and 111 women (41.0%) for whom albumin was prescribed (Table 1).

Dispersion of patients in different wards of the hospital and the amount of albumin prescribed in each ward

Other objectives of this study were the distribution of patients in different hospital wards and the amount of albumin prescribed in each ward. After that, men's internal ward with (11.07%) frequency, surgical ICU with (10.33%), internal ICU (9.96%), women's internal ward (8.12%), general ward (7.75%) ), Cardiac hospitalization (6.27%), emergency medical department (4.06%), emergency department (2.95%), pediatric ward (2.58%), Pediatric Intensive Care Unit (PICU) (2.21%), inpatient chemotherapy ward (1.48%), Neonatal Intensive Care Unit (NICU) (1.11%), The Coronary Care Unit (CCU) (0.37%), pediatric emergency department (0.37%), outpatient chemotherapy ward (0.37%), poisoning ward (0.37%) Percent) and neonatal ward (0.37 percent) were in the next positions (Table 2 and Figure 1 ).

The frequency of all patients studied according to the cause of albumin administration

In this study, the examined cases were also examined in terms of the cause of albumin administration. The cause of hospitalization was 113 patients (41.7%) with hypoalbuminemia. Other causes of hospitalization in order of frequency are paracentesis of cirrhotic ascites (30.63%), nutritional (11.07%), plasmapheresis (7.01%), peritonitis (2.21%), cirrhosis and nephrotic syndrome (21 2.2%), surgery (1.48%), hypovolemia (1.48%), SRDS (1.11%), cancer (0.74%) and diabetic proteinuria (0.37%) (Table 3 and Figure 2),

Frequency of all patients examined by recovery status

In this study, the final status of patients who received albumin was also evaluated, and the result was that out of 271 patients, 209 (77.1%) improved, and 69 (22.9%) died Were (Table 4).

The frequency of all patients examined separately for albumin drug approval by the hospital pharmacist

Of all the cases studied, 14 cases (5.2%) were approved by the pharmacist before receiving the albumin by the patient, and 257 cases (94.8%) were not authorized by the pharmacist (Table 5). In addition, with the presence of a clinical pharmacist at Shahid Rahimi Hospital, he was not advised to prescribe albumin in any of the cases.

Evaluation of whether or not it is reasonable to prescribe the drug to all patients examined based on UpToDate

Prescribing the drug was reasonable in 122 of the total cases (45.02%), and in 149 cases (54.98%), these prescriptions were not appropriate (Table 6).

Evaluation of hospitalization period, age, number of vials, and the number of expenses in all patients

The mean length of hospital stay in this study was 14.31 days (with a minimum of 1 and a maximum of 107 days). The mean age of patients was 53.3 years with a minimum of 0 and a maximum of 94 years). The number of vials consumed per patient varied from one to 116, and the average vial consumption in patients was 13.32. The average cost of total drug in dollars in the studied patients was $ 1843. The average price of albumin per patient was estimated at $ 553.04. The average cost for insurance was estimated at $ 1290,428. (Table 7).

Frequency of patients studied by irrational administration of albumin by hospital ward

The distribution of patients for whom irrational albumin administration was performed in different wards of the hospital and the amount of albumin administration in each ward were evaluated. They were hospitalized with albumin. Then, surgical ICU with (13.4%), internal ICU (10.1%), men's internal medicine ward with (8.1%), cardiac hospitalization (0.6%), women's internal medicine (3.4%), General Internal Medicine, Pediatric Ward and PICU each with (2.7%), Inpatient Chemotherapy Ward (0.2%), NICU (1.3%) followed by Emergency Room, CCU and Poisoning Ward each Were 0.7% (Table 9 and Figure 3).

Frequency of patients studied by irrational administration of albumin by gender

In this study, studies performed on all patients described were performed on a group of 149 patients in whom albumin administration was unreasonable to compare the results. 149 patients, including 89 men (59.7%) and 60 women (40.3%) for whom albumin was irrationally prescribed, were studied (Table 8).

Frequency of drug administration in patients studied with irrational albumin administration

The cause of drug administration was hypoalbuminemia in 75.8% of cases, followed by nutritional causes with 20.1% of cases, surgery with 2.7% of cases, and finally cancers with 1.3% of patients (Table 10 and diagram 4).Frequency of patients evaluated by irrational administration of albumin by recovery status

Regarding the recovery status of patients with irrational albumin administration, 75.2% (112 cases) of these patients improved, and 24.8% (37 cases) died (Table 11).

Frequency of patients evaluated by irrational administration of albumin separately for drug approval by the hospital pharmacist

Out of 149 cases of irrational albumin administration, 141 (94.6%) were not approved by the pharmacist, and only 8 (5.4%) were approved by the pharmacist (Table 12).

Evaluation of hospitalization duration, age, number of vials, and the costs in patients with irrational albumin administration

In this study, the mean length of hospital stay of patients with irrational albumin administration was 17.19 days (with a minimum of 1 and a maximum of 107 days). The mean age of patients was 54.83 years, with a minimum of 0 and a maximum of 94 years. The number of vials consumed per patient varied from one to 115, and the average vial consumption in patients was 7.84. The average total cost of the drug in dollars in the studied patients was $ 1084.87, the average price of albumin per patient was $ 325,434, and the average cost for insurance was $ 759,346. (Table 13).

Relationship between the number of vials consumed and the patient's recovery status

This study investigated the relationship between the number of vials consumed and the patient's recovery status. During this study, the Spearman coefficient was evaluated for 0.024 and coherent, so the relationship between these two variables is coherent but weak. Examining the P-value of these two variables, no significant association was found between them (p-value = 0.689) (Table 14).

Relationship between the number of vials consumed and the type of prescription

Also, the relationship between the number of vials and the type of administration was investigated. During the studies, the relationship between these two variables with a P-value of less than 0.0001 was significant, and the value of the spearman coefficient equal to + 0.242 indicates a relationship. It is consistent and moderate (Table 14). 16-1-3-R relationship between the type of administration and the patient's condition in the present study, the relationship between the kind of administration and the patient's condition was also examined. Still, the relationship between the two was not considered significant, with P-value = 0.399. Also, the Spearman coefficient, in this case, was equal to +0.051, which indicates a weak and consistent relationship (Table 15).The results showed that the mean albumin level before albumin administration in the study participants was 2.87±0.62 (g/dL). The results did not show a statistically significant difference in the mean albumin level before albumin administration based on gender and length of hospital stay in the study participants (P> 0.05) while the mean albumin level before albumin administration in the age group over 30 years and in patients who had partial recovery were significantly higher (p <0.05).

Figures & Tables

Albumin is not a drug that can be used as a calorie-suppressing protein in poor nutritional status or dietary supplements. Iatrogenic increase in blood albumin concentration to more than 4 g/dL increases catabolism in the body. In general, albumin should be prescribed to the patient to improve the balance of albumin synthesis rate and metabolism. Patients may experience severe diarrhea of more than 2 liters per day due to an enteral diet. In these patients, after ascertaining the cause of diarrhea, ruling out other possible causes, and switching diet from antral to parenteral, the blood albumin level should be below Keep 2 grams per deciliter [27-29]. A limited number of extensive controlled studies have been performed to evaluate the accuracy of albumin administration in medical centers and the unnecessary costs of prescribing this drug to patients and insurance companies. These studies differ in terms of design, objectives, and method of implementation [30-33].

In the present study, 271 patients, including 160 men (59.0%) and 111 women (41.0%) who were prescribed albumin, were studied, and out of 271 patients, 209 (77.1%) were Recovered, and 69 patients (22.9%) died. The primary purpose of this study was to evaluate the consumption and rationality of albumin administration in patients admitted to Shahid Rahimi Hospital in Khorramabad. In order to determine the distribution of patients in different wards of the hospital and the amount of albumin administration in each ward, it was found that the two wards of gynecological surgery and male surgery each with a frequency of 41 patients (15.13%) and CCU wards, ward. The pediatric emergency department, outpatient chemotherapy ward, poisoning ward, and neonatal ward had the frequency of one patient (0.37%) and had the highest and lowest percentages of patients admitted with albumin administration. The studies performed for all the patients described were also performed for a group of 149 patients in whom albumin administration was unreasonable to compare the results. In this study, 149 patients, including 89 men (59.7%) and 60 women (40.3%), for whom albumin drug was irrationally prescribed, were studied, and 75.2% (112 cases) were recovered. These patients improved, and 24.8% (37 cases) of them died. The two wards of gynecological surgery and male surgery each had a frequency of 34 patients (22.8%). Poisoning was 0.7% each. As described, both in the general examination of patients and in patients with irrational administration of albumin, it was found that the most use of albumin was in surgical wards (men and women). Therefore, in cases of albumin requests for patients admitted to these wards should be done with more supervision by the pharmacist.

Further monitoring will reduce the consumption of this vital drug and the costs incurred by patients and insurance companies. In addition, if each drug discussed in this study, albumin, is prescribed correctly and rationally, health services will be more effective for patients with fewer side effects. They will increase the quality of treatment and increase patient satisfaction. In the discussion of costs imposed on the patient and insurance companies in this study, the number of vials consumed per patient varied from one to 116, and the average vial consumption in patients was 13.32. The average cost of prescription drugs was estimated at $ 1843.46. The average price of albumin per patient was $ 553.04, and the average cost of insurance was estimated at $ 1290,428. In the group that prescribed albumin to irrational patients, the average cost of prescribed drugs was estimated at $ 1084.78. The average cost of albumin for a patient was $ 325.43, and the average insurance price was $ 759,346. As it is known, a very high fee is paid by patients due to irrational albumin administration, so that out of $ 250,711.73 total albumin administration for 3611 albumin vials, only $ 112870.42 (45.02%) of the total cost is spent on rational albumin administration and 54.98% The total consumption of albumin, i.e., 137841.31 dollars, is due to irrational prescriptions. These high costs will be reduced with more supervision, and the difference can be spent on creating better quality insurance benefits for patients. As previously described, in this study, no significant relationship was observed between the number of vials consumed and the state of improvement (P-value = 0.689), and the relationship between these two variables was evaluated as weak (Spearman coefficient equal to 0.024). From this, it can be fortunately concluded that the irrational administration of albumin to patients does not overshadow their recovery status and is not life-threatening for patients. However, it can expose patients to side effects without receiving therapeutic effects of albumin.

Also, the relationship between the number of vials and the type of administration was investigated. During the studies, the relationship between these two variables was significant (P-value less than 0.0001), and the spearman coefficient value equal to + 0.242 indicates a relationship. Alignment and intermediate communication. This suggests that in cases where patients have been given irrational prescriptions, albumin consumption is higher, and this shows the need for more control of pharmacists in prescribing this drug because although defining albumin for patients is not life-threatening. Still, consumption and its irrational administration have no therapeutic effects for the patient, but the patient is at risk of side effects of albumin and has a heavy financial burden for the health care system and the patient himself. In the present study, the relationship between the type of administration and the patient's condition was also examined, but the relationship between the two was not considered significant, with a P-value of P-0.399. Also, the spearman coefficient in this case was equal to +0.051, which indicates a weak and consistent relationship.

In conclusion, the process of administration of albumin in Shahid Rahimi Hospital in Khorramabad was not desirable and the adoption of policies such as adherence to the standard protocol Regarding the logical prescription of albumin, it can be helpful. Albumin is an expensive medication prescribed unnecessarily for many patients. Using the clinical pharmacist's prepared guideline could minimize the situations where its administration is not needed. The obtained results indicate the need to review and monitor the prescription of clinically important drugs, by preparing an in-hospital protocol, and the need to establish a pharmaceutical care department in the hospital in order to promote the rational prescription of drugs.

Author Contributions

Hadi Hayati Abbarik, Arian Karimi Rouzbahani: Data analysis 
Vahid Rahimi, Fanak Fahimi, Javad Ghasemian Yadegari: Monitoring of research 
Waleed K. Khawaja, Noora M. Hameed, Mohammad Karimi: Drafting 
Hadi Hayati Abbarik, Arian Karimi Rouzbahani, Zahra Heydari, Ali Kharazmkia: Manuscript scanning 
Vahid Rahimi, Fanak Fahimi, Javad Ghasemian Yadegari, Hadi Hayati Abbarik, Arian Karimi Rouzbahani, Zahra Heydari, Ali Kharazmkia: Data evaluation

Conflict of Interest

The authors declare that there is no conflict of interest.

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