Lampiran 1. Data demografi pasien DM tipe 2 Rawat Jalan di RSUP H.

Adam
Malik Medan

Model terapi No.Rekam Inisial Nama Jenis Umur

Antidiabetik Medik Pasien Kelamin
Metformin 00.00.00.20 RP PR 51
00.04.16.37 MN LK 78
00.01.18.72 SE LK 71
Metformin- LT PR 61
Glurenorm
00.03.06.07 PH LK 80
00.03.70.45 KG PR 58
00.00.70.60 A.B.H PR 68
Metformin- 00.03.59.12 R.PM LK 55
Glucodex
00.00.41.09 BS PR 79
Metformin- 00.00.09.22 S PR 46
Diaversa
00.04.99.24 DT LK 44
00.59.67.95 NK LK 49
Diaversa-Eclid 00.00.18.16 IG PR 52
00.01.04.83 TG LK 49
00.01.39.98 IK PR 65
Novomix 00.02.55.10 MG PR 47
00.03.14.14 SR PR 69
00.05.63.23 MS LK 66
00.04.37.05 MT PR 50
00.00.83.60 YS PR 63
00.01.98.81 BJ LK 78
00.00.55.97 PS PR 81
00.06.11.88 BO LK 53
Novomix- 00.01.08.42 DSB PR 61
Metformin
00.02.74.76 SB PR 52
00.02.90.72 EP PR 56
Novomix-Lantus 00.00.82.06 RT LK 73
00.03.35.71 NS PR 73

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Lampiran 2. Biaya Model Terapi Antidiabetes selama 3-4 bulan

No Model Terapi Harga satuan Jumlah Total Harga

Antidiabetik (Unit)

1. Metformin 156,00 519 80.964,00

2 Metformin-Glurenorm 156,00 - 1.620,00 644 - 420 780.864,00

3 Metformin-Glucodex 156,00 - 372,00 480 - 240 164.160,00

4 Metformin-Diaversa 156,00 - 660,00 810 - 420 403.560,00

5 Diaversa-Eclid 660,00 - 1.170,00 362 - 561 895.290,00

6 Novomix 121.900,00 123 14.993.700,00

7 Novomix-Metformin 121.900,00 - 56 - 510 6.905.960,00

156,00

8 Novomix-Lantus 121.900,00 - 35 - 13 5.537.250,00

97.750,00

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Lampiran 3. Perhitungan Distribusi Frekuensi Pasien DMT2

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Lampiran 4. Perhitungan Usia Rata-rata Pasien DMT2

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Lampiran 5. Contoh Perhitungan Efektivitas rata-rata KGD

Antidiabetes Metformin

No Nomor RM Penurunan Kadar Gula Darah (mg/dL)

1 00.00.00.20 15,5

2 00.00.00.20 10,8

3 00.01.18.72 11

Efektivitas Rata-rata = 15,5 - 10,8 - 11

3
= 12,43 mg/dL

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Lampiran 6. Contoh Perhitungan CER (Cost-effectiveness ratio)

Antidiabetes Novomix

CER =

= 1.874.216 (Rp)
22,75 (mg/dL)

= 82.383

Antidiabetes Metformin

CER =

= 26.988 (Rp)
12,43 (mg/dL)

= 2.171

Antidiabetes Kombinasi Novomix-Lantus

CER =

= 2.768.625 (Rp)
36,25 (mg/dL)

= 76.375

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Lampiran 7. Contoh Perhitungan ICER (Incremental cost-effectiveness ratio)

Antidiabetes Diaversa-Eclid (Obat A)

Antidiabetes Metformin (Obat B)

ICER =

= 298.430 26.988 (Rp)

16,91 12.43 (mg/dL)

= 271. 442 (Rp)

4,48 (mg/dL)

= 60.589

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Lampiran 8.

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Lampiran 9.

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Lampiran 10.

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Lampiran 11.

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