Budget impact analysis for three glucagon-like peptide-1 receptor agonist-based therapies for type 2 diabetes mellitus management in Saudi Arabia.

BACKGROUND AND OBJECTIVES: This study presents a budget impact analysis (BIA) conducted in Saudi Arabia, evaluating the cost implications of adopting semaglutide, tirzepatide, or dulaglutide in the management of type 2 diabetes mellitus (T2DM) patients. The analysis aims to assess the individual budgetary impact of these treatment options on healthcare budgets and provide insights for decision-makers. METHODS: A prevalence-based BIA was developed using real-world and clinical trials data. The model considered disease epidemiology, medication prices, diabetes management expenses, cardiovascular (CV) complications costs, and weight reduction savings over a 5-year time horizon. One-way and probabilistic sensitivity analyses (OWSA, PSA) were performed to assess the robustness of the results. RESULTS: Over a 5-year period, the cumulative budget impact for semaglutide, tirzepatide, and dulaglutide were 85,923,089 USD, 169,790,195 USD, and 94,558,356 USD, respectively. Hypothetical scenarios considering price parity between semaglutide and tirzepatide are associated with financial impacts of 85,923,091 USD and 86,475,335 USD, respectively. In the public sector, semaglutide showed the lowest incidence of 3-point major adverse CV events (3P-MACE), with tirzepatide leading in weight loss and HbA1c reduction, and dulaglutide presenting the highest 3P-MACE rates and least improvements in HbA1c and weight. A breakeven analysis suggested that tirzepatide's list price would need to be $199.91 lower than its current list price to achieve budget impact parity with semaglutide based on currently available evidence. Results from the OWSA suggested that risk reductions for CV events were key drivers of budget impact. PSA results were confirmatory of base-case analyses. CONCLUSIONS: CV cost-offsets and drug acquisition considerations may make semaglutide a favorable use of resources for Saudi budget planners and decision-makers. These results were robust to assumptions regarding the list price of tirzepatide.

Ten-year cost-consequence analysis of weight loss on obesity-related outcomes in privately insured adults with obesity in Saudi Arabia.

AIM: This study aimed to estimate the 10-year cost-consequence of weight loss on obesity-related outcomes in a sample of privately insured adults with obesity in Saudi Arabia (KSA). METHODS: We analyzed data of adults with obesity (BMI ≥ 30 kg/m2) available in Nphies, the private health insurance platform of the Council of Health Insurance, KSA. A micro-costing analysis was used to obtain domestic cost estimates for obesity-related outcomes. Cox proportional hazard models were used to estimate the benefit of weight loss by preventing incident cases of 10 obesity-related outcomes. RESULTS: In the study cohort (n = 314,079), the 30-34.9 BMI category contributed two-thirds of the cohort, and no gender differences were found in the age distribution of BMI categories. The elderly population had a higher prevalence of obesity-related outcomes, such as hypertension, osteoarthritis, and type 2 diabetes mellitus (T2DM). The baseline cost (2023) for treating these outcomes was USD 1.245 billion, which could double in 10 years. A 15% weight loss could save USD 1.295 billion over 10 years, with most savings due to T2DM (USD 430 million), given its higher prevalence (27.5%). The model was most sensitive to cost variability in T2DM, dyslipidemia, and hypertension. LIMITATIONS: The results should be interpreted within the bounds of the study cohort, and Nphies is in its early stages of implementation. The cost estimates may differ if repeated among adults with obesity only, potentially leading to increased cost savings with weight loss. CONCLUSIONS: Moderate weight loss of 5-15% over 10 years is associated with substantial cost savings in Saudi Arabia. For a 15% weight loss, 18.8% of incidence cases of obesity-related outcomes may be prevented, and slowed increases in T2DM, dyslipidemia, and hypertension may lead to considerable cost savings. The findings would help policymakers to implement weight loss programs in KSA.

Pharmacy practice in hospital settings in GCC countries: Dispensing and administration.

Purpose: To outline dispensing and administration practices in hospital pharmacy across the Gulf Cooperation Councils (GCC) countries' hospitals. Paucity of data in appraising hospital pharmacy practice in GCC regions motivated us to conduct this study. Methods: A modified survey questionnaire was prepared from the American Society of Health-System Pharmacist (ASHP) survey questions. Three major domains of questions for general characteristics of the medication use process for dispensing and administration were identified. These were, (1) medication distribution system, and medication distribution technology, (2) technology used to compound sterile preparations, compounding I.V. medication and method of compounding nutrition support preparations, (3) medication administration practices, medication orders, medication administration records (MARs), and technician activities. A list of hospitals was obtained from the Ministry of Health of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly. Results: Sixty-four hospitals responded to this survey. The overall response rate was 52%. Most surveyed hospitals have centralized inpatient medications distribution system (75.0%). About 37.5% of hospitals used automated dispensing cabinets (ADCs) in their patient care areas. Compounding sterile preparations in the pharmacy, barcode verification technology, workflow management technology, and robotic technology were used by 17.2%, 15.6%, and 4.7% of hospitals, respectively. In using safety technology for medication administration, almost all hospitals have partially or completely implemented an electronic health record (EHR). About 40.6% of hospitals used electronic medication administration records (e-MARs), 20.3% used bar-code-assisted medication administration (BCMA), and 35.9% used smart infusion pumps. Conclusion: The results of this survey revealed an opportunity to improve the medication use management process on dispensing and administration practices in hospitals in GCC countries.

Obesity Burden and Impact of Weight Loss in Saudi Arabia: A Modelling Study.

BACKGROUND: Obesity and its complications are associated with morbidity, mortality and high economic cost in Saudi Arabia. Estimating this impact at the population level and potential benefits to be gained from obesity reduction is vital to underpin policy initiatives to prevent disease risks. METHODS: We combined data in an adapted version of the value of weight loss simulation model, to predict reductions in complication rates and cost savings achievable with 15% weight loss in Saudi Arabia over 10 years. To obtain model inputs, we conducted a systematic literature review (SLR) to identify data on the prevalence of obesity and its complications in Saudi Arabia, and surveyed specialist physicians and hospital administrators in public (governmental) and private healthcare sectors. We used combinations of age, sex, obesity and type 2 diabetes (T2D) rates in Saudi Arabia to sample a United Kingdom (UK) cohort, creating a synthetic Saudi Arabia cohort expected to be representative of the population. RESULTS: The synthetic Saudi Arabia cohort reflected expected comorbidity prevalences in the population, with a higher estimated prevalence of T2D, hypertension and dyslipidaemia than the UK cohort in all age groups. For 100,000 people with body mass index 30-50 kg/m2, it was estimated that 15% weight loss would lead to a 53.9% reduction in obstructive sleep apnoea, a 37.4% reduction in T2D and an 18.8% reduction in asthma. Estimated overall cost savings amounted to 1.026 billion Saudi Arabian Riyals; the largest contributors were reductions in T2D (30% of total cost savings for year 10), dyslipidaemia (26%) and hypertension (19%). CONCLUSIONS: Sustained weight loss could significantly alleviate the burden of obesity-related complications in Saudi Arabia. Adopting obesity reduction as a major policy aim, and ensuring access to support and treatment should form an important part of the transformation of the healthcare system, as set out under 'Vision 2030'.

The Impact of Obesity in Saudi Arabia: Healthcare Resource Use and Costs Associated with Obesity-Related Complications.

INTRODUCTION: Saudi Arabia has a high prevalence of obesity, which increases the risk of individuals experiencing multiple chronic complications. Only a few publications highlight the healthcare costs of obesity-related complications (ORCs) in Saudi Arabia. METHODS: A micro-costing approach was used to estimate the healthcare costs associated with 10 ORCs. Experienced clinicians in public and private practice across different geographical regions in Saudi Arabia were asked to estimate healthcare resource use associated with each ORC, and estimated unit costs were obtained from hospital administrators. Estimated overall annual costs per patient were calculated as a weighted average of separate public and private sector costs. RESULTS: Individuals in Saudi Arabia with any single ORC incurred overall average annual healthcare costs of 2165-7558 US dollars (USD). Heart failure, chronic kidney disease, dyslipidemia, and type 2 diabetes (T2D) were the most costly complications, mainly driven by monitoring and/or pharmacological treatment costs. In contrast, asthma, hypertension, and angina were the least costly complications. Costs in private healthcare were higher than in public healthcare; the largest differences (2359-2793 USD) were noted for dyslipidemia, T2D, and osteoarthritis, mainly explained by differences in pharmacological treatment costs. CONCLUSIONS: These data suggest that ORCs result in a considerable financial burden to the healthcare system, and highlight the substantial cost savings that could be achieved by preventing or delaying the occurrence of ORCs in Saudi Arabia.

Preparatory Year Students' Perception of Pharmacy Profession as a Career Choice: A Cross-Sectional Study

Abstract The study attempted to assess preparatory year students' perception towards pharmacists and the pharmacy profession. This cross-sectional survey was conducted between December 2019 and March 2020. The students were invited to complete an anonymous questionnaire via Google Forms®. In total, 244 students, of which 53.7% were female with the mean age of 19.2 ± 0.65, from 12 universities participated in this study. As per our findings, the majority of the respondents (91.8%) regard pharmacy as a well-respected profession, 82.4% thought pharmacists are important decision-makers, 68.4% disagreed that most pharmacists were unkind, and 60.7% did not agree that pharmacy was a low-status occupation. Meanwhile, 95.5% agreed that pharmacists must have a university degree, 88.6% agreed pharmacists must take responsibility for patients, and 82.8% believed pharmacists had to work too hard. Moreover, 62.3% did not think pharmacy was a low-skill occupation, 54.9% did not agree pharmacists must do unpleasant things, and 45.1% disagreed pharmacists only did what physicians requested of them. Lastly, 48.8% had low confidence in choosing pharmacy as a career. The students' overall perception toward pharmacists and the pharmacy profession was favorable. However, only one-fourth of the students displayed a tendency to choose pharmacy as a future career.

Budget impact analysis of a bioprosthetic valve with a novel tissue versus mechanical aortic valve replacement in patients older than 65 years with aortic stenosis in Saudi Arabia.

AIMS: A budget impact analysis (BIA) comparing bioprosthetic valves with RESILIA tissue and mechanical valves in aortic stenosis (AS) patients > 65 years in the public and private sectors of Saudi Arabia. MATERIALS AND METHODS: A decision-tree with a partitioned survival model was adapted to estimate the financial consequences of either a RESILIA tissue valve or a mechanical valve in aortic valve replacement (AVR) procedures up to 5 years. The budget impact of resource consumption for both valve types was compared and included disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments. One-way sensitivity analyses (OWSA) were performed on cost and probability inputs. RESULTS: RESILIA tissue valves versus mechanical valves are overall budget saving commencing in Year 1 and savings gradually increase year-on-year. The higher costs of the initial procedure, reoperation, and additional monitoring (echocardiogram tests and visits) associated with RESILIA tissue valves are offset by savings in warfarin use, disabling strokes, major bleeding, and anticoagulation complications. The cost per initial procedure per patient is SAR795 higher for a RESILIA tissue valve reflecting the higher valve acquisition cost, which is partially offset by a shorter hospital stay. The OWSA suggests that total procedure costs of each valve, including the hospital stay, are the main cost drivers in the model. LIMITATIONS: The variability of cost inputs and the presence of multiple payers with multiple costing data is a key challenge in Saudi Arabia. Budget impact results may, therefore, change if repeated per AVR center and may also be impacted by the long-term durability of RESILIA tissue valves. CONCLUSIONS: An AVR in patients > 65 years with a RESILIA tissue valve is budget-saving from the first year in Saudi Arabia. Patients, payers, providers and policymakers may benefit economically from increased implantation of RESILIA tissue valves.

Criteria to define rare diseases and orphan drugs: a systematic review protocol.

INTRODUCTION: Rare diseases (RDs) are often chronic and progressive life-threatening medical conditions that affect a low percentage of the population compared with other diseases. These conditions can be treated with medications known as orphan drugs (ODs). Unfortunately, there is no universal definition of RDs or ODs. This systematic review (SR) will identify the quantitative and qualitative criteria and the underlying rationale used internationally to define RDs and ODs. METHODS AND ANALYSIS: This protocol follows the conventions for the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (2015 guidelines). A SR will be conducted, including a search of the following databases: PubMed, MEDLINE, EMBASE, Scopus, Web of Science, GreyLit and OpenGrey. Eligible publications will be selected based on predetermined inclusion criteria. Extracted data will be analysed using thematic and content analyses of qualitative descriptors, whereas quantitative data will be analysed descriptively and reported in the form of frequencies and percentages. ETHICS AND DISSEMINATION: No ethical approval is required since this SR focuses on the secondary analysis of data retrieved from the scientific literature. The outcomes of this SR will be published as part of a PhD thesis, presented at conferences, and published in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021252701.

Budget impact analysis of transcatheter aortic valve replacement in low, intermediate, and high-risk patients with severe aortic stenosis in Saudi Arabia.

AIMS: A budget impact analysis (BIA) comparing transcatheter aortic valve replacement (TAVR) with SAPIEN 3 and surgical aortic valve replacement (SAVR) for severe, symptomatic aortic stenosis among patients of low, intermediate, and high surgical risk from the perspective of the public and private sectors in Saudi Arabia. MATERIALS AND METHODS: A Markov model was developed with six states to calculate the budget impact from time of either TAVR or SAVR intervention up to 5 years. We compared the budget effects of new permanent pacemaker implantation (PPI), new onset atrial fibrillation (AF), major/disabling stroke (MDS), and surgical site infections (SSI). One-way sensitivity analyses (OWSA) were performed on cost and probability inputs. RESULTS: Analysis of the base case parameters suggests TAVR vs. SAVR is budget saving among intermediate- and high-risk patients at 5 years. TAVR vs. SAVR for low surgical risk reaches budget neutrality at 5 years. TAVR is associated with higher costs for PPI and budget savings for MDS, AF, and SSI. TAVR also results in savings for non-device costs due to fewer human resource uses and shorter procedure durations. Similarly, TAVR is associated with cost savings due to shorter hospital intensive care unit (ICU) and non-ICU stays. The OWSA consistently revealed that SAVR non-device theater costs were the leading cost driver across all surgical risk levels. LIMITATIONS: This is the first budget impact analysis of its kind in Saudi Arabia and future research is needed on costing TAVR and SAVR procedures, the economic impact of SSI, and corroborating estimates for the public and private sectors. CONCLUSIONS: Payers, providers, and policymakers increasingly turn to results of BIA to inform technologies affordability decisions. TAVR with SAPIEN 3 appears to generate savings vs. SAVR from a budget impact perspective across various surgical risk levels in Saudi Arabia.

Value drivers for pharmaceutical products in health technology assessment (HTA) in Saudi Arabia: Results from a capacity Building, Multi-Stakeholder workshop.

OBJECTIVES: Capacity building exercises are important to increase understanding of healthcare processes by key stakeholders, and to facilitate open discussions to build consensus. This study explored the views of a multi-stakeholder group of local Saudi experts on possible value elements that could be important for health technology assessment (HTA) processes and methods regarding pharmaceutical products in Saudi Arabia ('value drivers'). METHODS: A diversified group of local experts were invited to a two-day capacity building workshop from 18 to 19 December 2019 in Riyadh, Saudi Arabia. Information regarding the participants' demographic and educational/professional background, along with their self-assessed knowledge and experience of HTAs and the concept of value in the pharmaceutical market was collected. For each of 22 value drivers identified during a targeted literature search, participants were asked either to 'opt out' of its consideration for future HTA assessments, or rate it from 1 to 10 (low-high) on feasibility and acceptability. RESULTS: Efficacy and safety were the highest rated value drivers for acceptability and feasibility. Explicit cost-effectiveness thresholds had the lowest ratings for acceptability and feasibility. Participants highlighted data availability and accuracy as a potential challenge to HTA implementation in Saudi Arabia. CONCLUSIONS: Participants valued a pharmaceutical product's efficacy and safety alongside the consideration of disease characteristics for HTA processes. Participants also valued a binding HTA recommendation and the use of local real-world evidence, where available, to support HTA submissions.

Pharmacy practice in hospital settings in GCC countries: Prescribing and transcribing.

PURPOSE: To outline hospital pharmacy practices across the Gulf Cooperation Councils (GCC) countries' hospitals. METHODS: A modified survey questionnaire was prepared from the original 2019 American Society of Health-System Pharmacist (ASHP) survey questions. Survey details were discussed with some pharmacy directors for clarity and relevance. A list of hospitals were obtained from the Ministry of Health of each of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly. RESULTS: Sixty four hospitals responded to this survey. The overall response rate was 52%. About 47% of the surveyed hospitals considered their drug formularies as closed, and strict. Additionally, only 44% of hospitals compare the effectiveness of products, when taking formulary decisions for drug inclusion. Forty-four percent of hospitals have computerized prescriber order entry (CPOE / EHR) system functionality for formulary system management. At about 39.1% hospitals, pharmacists have the responsibility for managing medication therapies, majority were engaged in providing anticoagulation therapies. About 61% of hospital pharmacies in GCC countries receive medication orders electronically, through CPOE/EHR. Majority (66%) of the hospitals in GCC countries have an active Antimicrobial Stewardship Program (ASP) while only 40% of pharmacists have a key role in providing clinical support. About 57.8% of hospital pharmacy directors reported that pharmacists do not provide ambulatory care clinical pharmacy services in their hospitals. CONCLUSION: In GCC countries' hospitals, there are major areas for improvement to patient care of which pharmacists are uniquely qualified as the medication experts to have the most meaningful outcomes in all of the domains of safe medication use, medication therapy management, antimicrobial stewardship program and participation in outpatient clinics.

Exploring Physicians' Views, Perceptions and Experiences about Broad-Spectrum Antimicrobial Prescribing in a Tertiary Care Hospital Riyadh, Saudi Arabia: A Qualitative Approach.

Antimicrobial resistance (AMR) is a global public health threat associated with increased mortality, morbidity and costs. Inappropriate antimicrobial prescribing, particularly of broad-spectrums antimicrobials (BSAs), is considered a major factor behind growing AMR. The aim of this study was to explore physician perception and views about BSAs and factors that impact upon their BSAs prescribing decisions. Qualitative semistructured telephone interviews over an eleven-week period were conducted with physicians in a single tertiary care hospital in Riyadh, Saudi Arabia. Purposeful and snowball sampling techniques were adopted as sampling strategy. All interviews were audio recorded, transcribed verbatim, uploaded to NVivo® software and analysed following thematic analysis approach. Four major themes emerged: views on BSAs, factors influencing BSA prescribing and antimicrobial stewardship: practices and barriers and recommendations to improve appropriate BSA prescribing. Recommendations for the future include improving clinical knowledge, feedback on prescribing, multidisciplinary team decision-making and local guideline implementation. Identification of views and determinants of BSA prescribing can guide the design of a multifaceted intervention to support physicians and policymakers to improve antimicrobial prescribing practices.

Evaluating the appropriateness of carbapenem and piperacillin-tazobactam prescribing in a tertiary care hospital in Saudi Arabia.

BACKGROUND: Antimicrobial resistance (AMR) is presently considered an emergent major global public health concern and excessive and/or inappropriate use of broad-spectrum antimicrobials contribute to the development of AMR. OBJECTIVE: To evaluate the appropriateness of carbapenems and piperacillin-tazobactam use in a tertiary care hospital. METHODS: A retrospective, observational, cross-sectional, drug-utilization study was conducted. The study included all adult hospitalized patients who had received at least one dose of the antimicrobials during their admission for the period between 1 January 2016 and 31 December 2017. The appropriateness of antimicrobial therapy was evaluated according to the Infectious Diseases Society of America (IDSA) guidelines with the consideration of the institutional antibiogram. RESULTS: Overall, 2731 patients received 5005 courses with one of the antimicrobials, for a total of 5045.9 defined daily doses (DDD) of imipenem-cilastatin, 6492.3 of meropenem and 15,595 of piperacillin-tazobactam (4.93, 6.34 and 15.24 DDD/100 bed days, respectively). The mean age of the patients who received either antimicrobial was 55.5 ± 20.3 years, with a 14-day average length of hospital stay. About half (52%) of the prescriptions were written for patients treated in the medical ward. Pneumonia (26.6%) and sepsis (24.9%) were the most common indication for the initiation of antimicrobial therapy. Of the assessed prescriptions, only 2787 (56.5%) were prescribed appropriately, with 2142 (43.5%) deemed inappropriate. The three most common reasons for inappropriate prescription were: the spectrum of activity was too broad (44.6%), followed by antimicrobial use without culture request (32.4%), and failure of suitable antimicrobial de-escalation (19.9%). CONCLUSIONS: The study indicates that the overall rate of inappropriateness was high, emphasizing the need to develop initiatives to effectively improve broad-spectrum antimicrobial prescribing.

Impact of a multidisciplinary intensive education program on type 2 diabetes mellitus patients' glycemic control and cardiovascular risk factors.

OBJECTIVES: To evaluate the impact of a multidisciplinary intensive education program (MIEP) on type 2 diabetes mellitus (T2DM) patients' outcomes. METHODS: A retrospective study was used to evaluate the impact of MIEP on T2DM patients' outcomes for between May 2016 and May 2017. Data were collected from the diabetes education clinic in King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia where patients were referred from diabetes outpatient clinics to the diabetes education clinic to receive MIEP. In terms of measuring the clinical outcomes of the T2DM patients, glycemic control, blood pressure, weight, and lipid profiles were assessed before MIEP at 3, 6, and 12 months. Results: A total of 174 patients with T2DM fulfilled study inclusion criteria. The results indicate improved glycemic control where patients' HbA1c and blood sugar levels were significantly reduced 3, 6, and 12 months after MIEP compared to the baseline (p less than 0.005). Moreover, blood pressure improved after education; a significant improvement was observed in the mean systolic blood pressure (SBP) from baseline to 12 months (p=0.036), and in the mean diastolic blood pressure (DBP) after 12 months (p=0.016). Additionally, the study found significant differences in total cholesterol and low-density lipoprotein (LDL) cholesterol 6 months after the intervention (p=0.014, p=0.02, respectively). Conclusion: Implementing an MIEP for T2DM patients can improve their clinical outcomes, which consequently may delay the disease's long-term complications.

The ticking time bomb in lifestyle-related diseases among women in the Gulf Cooperation Council countries; review of systematic reviews.

BACKGROUND: This study aims to review all published systematic reviews on the prevalence of modifiable cardiovascular disease risk factors among women from the Gulf Cooperation Council countries (GCC). This is the first review of other systematic reviews that concentrates on lifestyle related diseases among women in GCC countries only. METHOD: Literature searches were carried out in three electronic databases for all published systematic reviews on the prevalence of cardiovascular disease risk factors in the GCC countries between January 2000 and February 2016. RESULTS: Eleven systematic reviews were identified and selected for our review. Common reported risk factors for cardiovascular disease were obesity, physical inactivity, diabetes, metabolic syndrome and hypertension. In GCC countries, obesity among the female population ranges from 29 to 45.7%, which is one of the highest rates globally, and it is linked with physical inactivity, ranging from 45 to 98.7%. The prevalence of diabetes is listed as one of the top ten factors globally, and was reported with an average of 21%. Hypertension ranged from 20.9 to 53%. CONCLUSIONS: The high prevalence of lifestyle-related diseases among women population in GCC is a ticking time bomb and is reaching alarming levels, and require a fundamental social and political changes. These findings highlight the need for comprehensive work among the GCC to strengthen the regulatory framework to decrease and control the prevalence of these factors.

Prescribing of potentially inappropriate medications among the elderly population in an ambulatory care setting in a Saudi military hospital: trend and cost.

AIM: To explore the prevalence of potentially inappropriate medication (PIM) use in the elderly, to identify the trends and the patterns of prescribing such medication, and to calculate the associated direct medication cost of such practice in a Saudi hospital. METHODS: This was a retrospective cross-sectional study of patients who were aged 65 years or older on at least one PIM. The source of our data was outpatient pharmacy prescription records at Riyadh Military Hospital (RMH) for 2002, 2003 and 2004. Beers' explicit criteria for PIM was used to identify these medications. RESULTS: A total of 20521 PIM were identified. The prevalence of PIM for 2002, 2003 and 2004 was 2.5%, 2.3% and 2.1%, respectively. A total of 43.6% of the patients had filled a prescription of one PIM, 18% filled two PIM and 38.4% filled three or more PIM. Digoxin accounted for 23.7% of these PIM. The most commonly prescribed medications were cardiovascular medications at 26.7%. The total direct cost that was associated with inappropriate prescribing was 518314 Saudi Riyals (US$138217) during the study period. CONCLUSION: PIM prescribing in RMH was less compared with what was published in the literature in other countries. It was unclear whether these results reflect the level of elderly healthcare services provided to RMH patients or because of underreporting. Drug utilization review programs, medical education, recruiting physicians and clinical pharmacists who are specialized in geriatrics, finding safer medications or integration of computer software to detect such medications during prescriptions entry can improve the medical services provided to the elderly.