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JMPF Vol. 8 No. 2: 70 – 79

ISSN-p : 2088-8139
ISSN-e : 2443-2946

Cost Effectiveness Analysis of Crystalloids and Crystalloid-Colloid

Combinations in Dengue Fever Without Shock at Bhakti Asih General
Hospital, Tangerang

Cost Effectiveness Analysis of Crystalloid and Crystaloid - Colloid Combination on Dengue Fever Without
Shock in Bhakti Asih General Hospital Tangerang

Suratni1.2*, Yusi Anggriani1, Agusdini Banun2

. Hospital Pharmacy, Master of Pharmacy, Pancasila University Jakarta 12640, Indonesia
. Bhakti Asih General Hospital, Jl. Raden Saleh No. 10 Tangerang

Banten 15148Submitted: 02-20-2018 Revised: 29-03-2018 Accepted: 07-30-2018

Correspondence: Suratni : Email: magisterfarmasiup@gmail.com

ABSTRACT
Dengue fever is an infectious disease caused by a virus that is transmitted through mosquitoes
Aedes aegypti. The high incidence of dengue fever can cause an increase in the health budget, especially
the cost of drugs and medical consumables during hospitalization. This study was conducted to analyze
the effectiveness and direct medical costs of dengue fever patients without shock in the use of fluid
therapy by comparing the use of crystalloid fluid therapy and the combination of crystalloid and colloid
using the cost-effectiveness analysis method. The study subjects were 171 patients divided into two
groups, 106 patients with crystalloid fluid therapy and 65 patients with crystalloid and colloid combination
therapy. An assessment of the effectiveness of treatment and the calculation of the average direct medical
costs were carried out. The results of the study showed that the effectiveness of treatment was seen from
the improvement in the hematocrit value, there was no difference (p>0, 05) in both study groups. The
average total cost of treatment for crystalloid fluid therapy is IDR 4,005,223 and combined crystalloid and
colloid fluid therapy is IDR 5,525,407. The highest cost was in the cost of drugs with a percentage of 31.75%
of the total cost of crystalloid solutions and 40.9% of the total costs of combined crystalloid and colloid
fluids. There is a significant difference in the mean cost between the two research groups (p<0.05) Value
Average Cost Effectiveness Ratio (ACER) for crystalloid liquid is (Rp 7,868,807) smaller than the combination
of crystalloid and colloid (Rp 9,445,140). There was a significant difference (p<0.05) in direct medical costs
to differences in treatment class, type of patient payment and nutritional status, but not significantly
different (p>0.05) on the effectiveness of treatment. In conclusion, crystalloid solutions have the same
effectiveness as a combination of crystalloid and colloid solutions with lower therapeutic costs.

Keywords: cost-effectiveness analysis, dengue fever, hematocrit, crystalloid, combination of crystalloid and colloid

ABSTRACT
Dengue fever is an infectious disease caused by virus transmitted through Aedes aegypti. The high
incidence of dengue fever can lead to increased healthcare costs. This study was conducted to analyze the
effectiveness and direct cost of medical patients dengue fever without shock use fluid therapy by comparing
crystalloid and crystalloid colloid combination. The subjects were 171 patients divided into two groups: 106
patients with crystalloid and 65 patients with crystalloid colloid combination. Assessed of effectiveness of
treatment and the mean medical costs. The results showed reviewed from hematocrit value no difference
(p>0.05) in both study groups. The mean total cost of treatment for crystalloid is IDR 4,005,223, the crystalloid
colloid combination is IDR 5,525,407. The highest cost of drug costs was 31.75% of the total cost crystalloid, 40.9%
of the total cost crystalloid colloid combination. There was a significant difference between the mean cost and
two study groups (p<0.05). ACER value for crystalloid was Rp 7,868,807 smaller than crystalloid colloid
combination Rp 9,445,140. There was a significant difference (p<0.05) in the direct medical cost of different
treatment groups, type patient payment, nutritional status, not significantly different (p>0.05) with treatment
effectiveness. Conclusion crystalloid have the sameeffectiveness as crystalloid colloid combination fluids at lower
costs.
Keywords: cost effectiveness analysis, crystalloid solution, crystalloid-colloid combination, dengue fever,
hematocrite.

70 JMPF Vol 8(2), 2018

Suratni, et al
PRELIMINARY
Dengue fever is a disease caused by a
viral infection
transmitted by mosquitoes Aedes aegypti.
Dengue fever cases can increase morbidity
and mortality rates and is one of the causes of
extraordinary events (KLB) in public health.1
according to World Health Organization (
WHO) in the last decade, it is estimated that
2.5 billion or two fifths of the world's
population are at risk of contracting dengue
fever, especially in tropical and subtropical
countries. It is reported that 52% of the
population resides in Southeast Asia.
Indonesia is one of the countries with the
highest incidence rate in Southeast Asia with
case fatality rate (CFR) of 0.89% in the period
1968-20091,2,3.
In handling dengue fever according to
WHO standards in 2009 and National
guidelines for clinical management of dengue
feverIn 2014, fluid therapy was the main
treatment for dengue fever. There are several
choices of fluid therapy used, namely
crystalloid and colloid fluids, the use of which
is adjusted to the severity of dengue fever.4.5
In the management of dengue fever with
shock and hematocrit levels > 20, colloid fluid
is given6. Studies conducted in patients with
hypovolemia, use of crystalloids and colloids
did not produce a significant difference in
reducing the risk of severity to death.7
Another study that assessed the effectiveness
and safety of using colloids in patients
requiring fluid resuscitation showed that
crystalloids and colloids were equally
effective.8. Regulation of the Minister of
Health Number 59 of 2014 concerning
standard tariffs
service
health in the implementation of health program
insurance. Amount of claim payment
by Body Organizer
Guarantee Social (BPJS) to facilities
health reference advanced level on
package service based on
to grouping disease diagnosis
JMPF Vol 8(2), 2018
and procedures. The service fee includes the
use of medicines and medical devices9.10.
Limited budget
available so required election
use of drugs with due regard to quality and cost
control. The application of pharmacoeconomic
studies in the selection and use of drugs
effectively and efficiently is needed to analyze
drug costs. One of the pharmacoeconomic
studies is cost-effectiveness analysis, namely by
comparing the cost and effectiveness of
alternative treatments according to the value of
Average Cost Effectiveness Ratio (ACER) and
Incremental
Cost Effectiveness Ratio (ICER) per
treatment.11 The number of dengue fever
patients at Bhakti Asih General Hospital in 2014
was 537 patients and in 2015 it was 214 patients.
The resuscitation fluids used are crystalloid and
a combination of crystalloid and colloid fluids.
The price difference between the two liquids is
quite significant, the price of the liquid
colloid more expensive compared to fluid
crystalloids. In collecting patient payments
with the National Health Insurance (JKN)
insurance for cases of dengue fever, the team
reportedcasemix hospital that 60% of the bill
exceeds the rate of Indonesia Case Base
Group (INA-CBG's).
The high cost of colloid fluids and the
large number of patients each year are a
concern in determining which standard of
treatment should be chosen from several
alternative treatments. Therefore, there is a
need for research on the cost-effectiveness
analysis of crystalloid fluids
and combination of crystalloid and
colloids in dengue fever without shock at
Bhakti Asih General Hospital. The purpose of
this study was to obtain data on the
effectiveness of using crystalloid fluids and
the combination of crystalloids and colloids in
dengue fever without severe shock
expected could used
as consideration in election
fluid on therapy fever bloody
taking into account the quality and costs in
the hospital.
71

RESEARCH METHODS
The research was carried out by the
method ofCross sectional, data retrieval
retrospectively using the methodtotal
sampling. The research subjects were patients
with dengue fever without shock with grade 1
and grade II in 2014 and 2015. Inclusion
criteria were patients with dengue fever
without shock (grade I and grade II), patients
aged > 17 years and using crystalloid fluid
therapy and a combination of crystalloids.
and colloids. Exclusion criteria were patients
with dengue fever accompanied by other
diseases. The material used is medical records
of patients with a diagnosis of dengue fever
without shock (degrees I and II) in 2014 and
2015. The data obtained are information on
patient characteristics (age, gender, body
mass index, treatment class, type of payment
andLength of Stay), laboratory data
(hematocrit, platelet, hemoglobin and patient
length of stay) and direct medical cost data
(drug costs, support, room rental, visit
doctors, administration and miscellaneous
costs and total costs). Direct medical costs in
2014 are adjusted to 2015discountfollow
consumer price index (CPI) 2015. Data were
analyzed descriptively on patient
characteristics data. The effectiveness of
treatment and direct medical costs were
analyzed using statistical tests using the SPSS
version 16.0 application and cost-
effectiveness analysis using ACER calculations
(Average Cost Effectiveness Ratio).
RESULTS AND DISCUSSION
Patient clinical characteristics
The number of patients who met the
inclusion criteria were 171 patients divided
into 106 patients given crystalloid fluids and
65 patients given a combination of crystalloid
and colloid fluids. The distribution of patient
characteristics by gender category showed
that in the crystalloid fluid group, the largest
percentage for the sex of dengue fever
patients without shock was female with a total
of 61 patients.
72
Crystalloid Cost Effectiveness Analysis
(57.6%). In the combined crystalloid and
colloid fluid group, the highest percentage
was male with 36 patients (55.4%) (Table I).
The age category of dengue fever patients
without shock is the largest in the productive
age, namely 18-35 years. Data from the
Center for Epidemiological Data and
Surveillance of the Ministry of Health of the
Republic of Indonesia in 2010 and research
conducted by WK Cheah in Malaysia, 34% of
patients with dengue fever were aged 20-29
years and aged > 15 years.1.3.
The largest percentage of patient
payments, namely payments through non-JKN
insurance and the largest class of care were
treated in classes 2 and 3 with normal
nutritional status with Length of Stay (LOS) for
3-5 days. Nutritional status is described by the
value of Body Mass Index (BMI). Nutritional
status can affect the host's immunity to
infection, if a person with poor nutritional
status caused by an imbalance in nutrient
intake and absorption, can damage the
immune system and can affect the patient's
treatment process.13.19.
Treatment effectiveness
Parameter effectiveness treatment
seen from the value of hematocrit, platelets,
hemoglobin and length of stay of patients in the
hospital. Parameters for the improvement of dengue
fever can be seen from the hematocrit value.
Existence enhancement score hematocrit
indicates the presence of plasma leakage
resulting in shock4.5. Existence
improvement in hematocrit value, platelet value,
hemoglobin value of the patient and the length of
the patient's stay showed the percentage of
treatment effectiveness (Table II). The percentage
of the effectiveness of treatment using crystalloid
fluids or a combination of crystalloids and colloids
has the same effectiveness, in the administration of
repair crystalloid fluids with a percentage of 50.9%
and in the combination of liquid crystalloids.
crystalloids and colloids by 58.5%. There was
no significant difference (p>0.05) between
group of patients who were given crystalloid solutions
and a combination of crystalloids and colloids to the
hematocrit value. Fluid administration
JMPF Vol 8(2), 2018
Suratni, et al

Table I. Data Characteristics of Dengue Fever Patients Without Shock and Other Clinical Characteristics

Research Subjects n= 171

Crystalloid + colloid
Variable Category Crystalloid (RL) n=106
(RL+Gelofusin) n=65
n%n%
Man 45 42.4 36 55.4
Gender
Woman 61 57.6 29 44.6
18-25 25 23.6 24 36.9
26-35 46 43.4 20 30.8
Age
36-45 18 16.9 11 16.9
> 45 17 16.1 10 15.4
Non Insurance 66 62.3 33 50.8
JKN
Type of payment
JKN Insurance 12 11.3 7 10.8
Individual/cash 28 26.4 25 38.4
Class 1 27 25.5 17 26.1
Grade 2 37 34.9 28 43.1
Class treatment
Grade 3 37 34.9 20 30.8
VIP 5 4.7 0 0
< 18.5 Kg/m² 17 16.0 9 13.9
18.5-25 Kg/m² 59 55.7 33 50.8
BMI
26-30 Kg/m² 26 24.5 16 24.6
> 30 Kg/m² 30 28.3 7 10.8
<3 days 2 1.9 0 0.0
LOS (Length of stay) 3-5 days 73 68.9 39 60.0
> 5 days 31 29.3 26 40.0

colloids did not show a significant difference
in reducing the risk of severity to death in
hypovalemic patients7. The choice of
resuscitation fluid with respect to restoration
of plasma volume and hemodynamic stability
has the same effectiveness as crystalloid and
colloid fluids7,8,14.
There were differences in platelet values in
the group of patients who were given crystalloid
solutions and the combination of crystalloids and
colloids that were significantly different (p<0.05).
This is because the measurement of the platelet
value is carried out on the third or fifth day of
hospitalization, where the patient is still in a critical
phase with symptoms of a decrease in platelet
value until the seventh day of dengue fever, so that
the platelet value is not the main parameter to
assess the effectiveness of treatment. The value of
platelets in the Dengue Fever (DHF) cycle can
decrease according to the
clinical manifestations between day 5-7 DHF
cycle4,5,15,22. On the old WK Cheah research
Treatment with primary infection with
treatment duration of 3-5 days and with
secondary infection 9-13 days3. From data
length of stayshowed the largest percentage
of both groups with 3-5 days of treatment.
The choice of colloid resuscitation fluid still
needs sufficient studies to be recommended
as an option16. This shows that there is a
relationship between the use of crystalloid
fluids and the combination of crystalloid and
colloid fluids to have the same effectiveness.
Medical direct costs
Direct medical costs are costs that are
directly related to health care9. Average cost
for 2014 which has been adjusted to 2015
discountfollow consumer price index (CPI)
2015.

JMPF Vol 8(2), 2018 73


The highest cost was in the cost of drugs with
a percentage of 31.75% of the total cost of
crystalloid solutions and 40.9% of the total
costs of combined crystalloid and colloid
fluids (Table III). Research conducted by
Nadra and Lucy CS Lum on health costs costs
40-60% of the health care budget with the
largest percentage on the cost of drugs and
medical consumables.15,17. The average cost of
crystalloid fluid therapy (Rp. 4,005,223) is
smaller than that of combined crystalloid and
colloid fluid therapy (Rp. 5,525,407) with the
largest percentage of costs being drug costs
(Table IV). There was a significant difference
in drug costs, support costs, visite costs,
administration costs and total costs (p<0.05),
and not significantly different (p>0.05) in
room rental costs. In terms of drug costs, the
combination of crystalloid and colloid fluids
with the addition of at least 2 colloids of
colloid fluid on 3 days of hospitalization
affects the patient's drug costs, as well as
supporting costs, doctor visits, administrative
costs and total direct medical costs.2.20.
Differences in nutritional status, treatment
class and type of payment on the effectiveness
and direct medical costs
Difference status nutrition could
described from the patient's Body Mass Index
value. The largest percentage of dengue fever
patients with normal nutritional status is
18.5-25 kg/m² (Table I) there is no difference
(p>0.05) between treatment effectiveness
parameters (hematocrit value, hemoglobin,
platelets, LOS) and nutritional status based on
BMI values (Table V). Huyen Trang Nguyen et
al results of a review of 13 previous studies
conducted in Japan on the relationship of
nutritional status in pediatric patientsDengue
Haemorrhage Fever (DHF)
74
Crystalloid Cost Effectiveness Analysis
and Dengue Fever (DF), it was found that
there was no relationship between the
severity of dengue fever and the nutritional
status of patients, both in malnutrition and in
obese patients25.26. there was no difference in
BMI value (p>0.05) on direct medical costs.
This shows that differences in BMI do not
affect the direct medical costs of patients.
Statistical results showed no difference
(p>0.05) between treatment classes on the
effectiveness of treatment (Table V). There
was no difference (p>0.05) in the class of
treatment to the direct medical costs of the
patient, indicating that the difference in the
class of treatment was not significantly
different from the direct medical costs,
namely the average cost of drug costs and
medical support costs, but there was a
significant difference (p<0.05 ) to the cost of
renting a room, costsvisit, administrative
costs, miscellaneous costs and the total direct
medical costs of patients with. Some
companies have drug standards and different
rates for each company which result in
differences in direct medical costs, especially
in drug costs, room rent, administration,
other costs and total direct medical costs.
Cost effectiveness analysis
The effectiveness of treatment in the
group given crystalloid fluids was 50.9% with
improvement requiring an average cost of Rp.
4,283,348 and the group given liquids.
combination of crystalloid and colloid by 58.5%
with repairs and requires an average cost of
Rp 4,839,252 (Table VI). This shows that with
the same percentage of improvement, the
combination therapy of crystalloid and colloid
fluids requires a higher cost.
Cost effectiveness analysis is calculated
by the value of Average Cost Effectiveness
Ratio(ACER). The ACER value for crystalloid is
smaller than the ACER value for fluid
combination therapy crystalloids and colloids
(Table VII). Score ACER describes
that with the ratio of the cost of treatment per
patient compared to the effectiveness
JMPF Vol 8(2), 2018
Suratni, et al

Table II. Treatment Effectiveness Data

Crystalloid + colloid
Crystalloid (RL) n = 106
Treatment Effectiveness (RL+Gelofusin) n = 65 p-value
N % N %
Hematocrit (Ht)
Repair 54 50.9 38 58.5
0.340
No Repair 52 49.1 27 41.5
Platelets (Thrombocytes)
Repair 52 49.1 15 23.1
0.001
No Repair 54 50.9 50 76.9
Hemoglobin (Hb)
Repair 67 63.2 49 75.4
0.099
No Repair 39 36.8 16 24.6
Length Of Stay
<3 days 2 1.9 0 0.0
3-5 days 73 68.9 39 60.0 0.115
> 5 days 31 29.3 26 40.0

Table III. Proportion of Patient's Direct Medical Cost

Research Subjects n=171

Crystalloid + colloid
Medical direct costs Crystalloid (RL) n=106
(RL+Gelofusin)n=65
Total Cost(Rp) % Total Cost (Rp) %
Drug costs 134,811,792 31.8 146,823,055 40.9
Support costs 76,730,355 18.0 52,780,387 14.7
Room rental fee 118,448,775 27.9 70,437,888 19.6
Cost visit doctor 41,624,705 9.8 30,558,300 8.5
Administrative costs 19,257,517 4.5 17,494,666 4.9
Miscellaneous expense 33,680,535 7.9 41,057,158 11.4
Total Cost 424,553,678 100 359,151,452 100

treatment obtained showed (Table VII). The To determine whether it is necessary to

ACER value illustrates that the ratio of the cost
of treatment per patient compared to the
effectiveness of the treatment obtained
shows that the treatment provided is more
effective and efficient12.
In addition to the ACER value, in the
cost-effectiveness analysis it can be included
inQuadrant Cost Effectiveness Plan (Figure 1)
with the results of crystalloid fluid therapy in
dominance so that it can be used as an option
in fluid therapy in dengue fever patients.
calculate the value of Incremental Cost
Effectiveness Ratio (ICER), can fill in the table
of alternative treatment positions (Figure 2).
The position of alternative treatment can be
explained that alternative treatment of
crystalloid fluid in column D position, it can be
interpreted that with lower costs the same
effectiveness is obtained. For the combination
of crystalloid and colloid liquids located in
column F, this means that the higher cost has
the same effectiveness. The picture of cost
effectiveness above results that at

JMPF Vol 8(2), 2018 75

 Crystalloid Cost Effectiveness Analysis

Table IV. Medical Direct Cost Data

Average cost (rupiah)

Medical Direct Cost Crystalloid After Crystalloid+Colloid After p-Value
customized Customized
Drug Cost 1,271,809 2,258,816 0.001
Support Fee 723,871 812.006 0.010
Room Rental Fee 1,117,441 1,083,660 0.849
Cost Visite 392,686 470.128 0.025
Administrative costs 181,675 269,149 0.004
Miscellaneous expense 317,741 631,649 0.442
Total Cost 4,005,223 5,525,407 0.001

Table V. Differences in Nutritional Status, Class of Treatment and Type of Payment on Treatment
Effectiveness and Cost

p-value
Treatment and Cost Effectiveness
Nutritional status Class treatment Type of payment
Hematocrit 0.289 0.120 0.985
Platelets 0.226 0.482 0.136
Hemoglobin 0.125 0.516 0.533
LOS 0.282 0.230 0.071
Drug Cost 0.272 0.205 0.001
Support Fee 0.59 0.638 0.379
Room Rental Fee 0.073 0.000 0.000
Visite Fee 0.481 0.001 0.822
Administrative costs 0.264 0.000 0.000
Miscellaneous expense 0.305 0.000 0.000
Total Cost 0.087 0.000 0.047

Table VI. Comparison of Treatment Effectiveness to Average Cost

Crystalloid + colloid
Effectiveness Crystalloid (RL) n = 106
Average Cost (RL+Gelofusin) n = 65 Average Cost
Treatment
(Rp) (Rp)
n % n %
fix 54 50.9 4,283,348 38 58.5 4,839,252
no Repair 52 49.1 3,639,359 27 41.5 6,417,977

Table VII. ACER Value

ACER
Average Medical Direct Cost Therapeutic Effectiveness
Types of Fluid Therapy (Average Cost
(Rp) (%)
Effectiveness Ratio)
crystalloid 4,005,223 50.9 7,868,807
crystalloid + colloid 5,525,407 58.5 9,445,140

76 JMPF Vol 8(2), 2018

Suratni, et al

Effectiveness
Not enough More

More Combined fluid therapy (RL+

expensive Gelofusin)

B
i
a
y
a

More Crystalloid (RL) (CEA Useful)

(CEA Useful)
inexpensive Domination

Figure 1. Quadrant Cost Effectiveness Plan Against the Crystalloid Group and the Combination of
Crystalloids and Colloids.

More cost
Cost Effectiveness Same cost Higher cost
low

More effectiveness
A B C
low

D F
Same effectiveness Liquid group E Liquid group
Crystalloid Crystalloid+colloid

More effectiveness
tall G H I

Figure 2. Position of Alternative Medicine

Description: Column D, G, H = dominant, column B, C, F = dominated, column E = balanced and column A, I calculate ICER

JMPF Vol 8(2), 2018 77


alternative position crystalloid fluid (column D)
not needed ICER calculation,
Likewise, the group of crystalloid and colloid
fluids (column F) does not require ICER
calculations because crystalloid fluids are
already in the dominant position and
crystalloid and colloid fluids are in the
dominant position.10.
CONCLUSION
The effectiveness of fluid therapy for
patients with dengue fever without shock with
crystalloid solutions and combinations of
crystalloids and colloids is the same, and the
mean costs incurred for crystalloid fluids are
lower than for combined crystalloid and colloid
fluids. The ACER value in the crystalloid fluid
group was smaller than the combined crystalloid
and colloid fluid group. Fluid therapy for dengue
fever patients without shock at Bhakti Asih
General Hospital is morecost effectiveness using
crystalloid fluid therapy compared to a
combination of crystalloid and colloid fluids. It is
hoped that with quality and cost control, an
effective and efficient use of fluid therapy will be
achieved so that hospital rates are still included
in the INA-CBG rates.
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