University of Southern California Week 11 Pharmacy Services and CBA Paper Summary of the lecture attached, like last time. thank you…………………..

University of Southern California Week 11 Pharmacy Services and CBA Paper Summary of the lecture attached, like last time. thank you………………………. Pharmacy Services
History and value of pharmacy
services
Rascati (Chapter 12)
1
Learning objectives
1. Describe the term ‘pharmacy services’
2. Describe how outcomes are measured when evaluating
pharmacy services
3. Discuss the history and trend of research on the value of
pharmacy services
2
What is Pharmacoeconomics?
•Pharmacoeconomics is the identification, measurement,
and comparison of the costs and outcomes of pharmacy
products (e.g., drugs) or services
―Bootman, 2005
3
What are pharmacy services?
• Pharmacy services consist of a variety of functions performed
by a pharmacist that may or may not be associated with the
dispensing of a particular prescription order
• Examples of pharmacy services include:
―Pharmacokinetic monitoring
―Patient education to improve medication adherence
―Drug utilization review (DUR)
4
Other names synonymous with pharmacy
services
1.
2.
3.
4.
5.
6.
Pharmaceutical care services
Medication therapy management (MTM)
Clinical pharmacy services
Cognitive pharmacy services
Disease-state management
Pharmacist’s intervention
5
How are outcomes
measured when evaluating
pharmacy services?
6
How to measure outcomes (the denominator) when
evaluating pharmacy services
• CBA is the analysis most often used to evaluate pharmacy services; however,
CEA and CUA can also be used
• CBA
―Direct benefits, indirect benefits (via human capital method), and intangible benefits (via
willingness to pay methods)
→Human capital method estimates value of health benefits or the economic productivity they
permit
→WTP methods estimates what patients would pay for pharmacy services
―Outcome or benefits=amount of dollars saved due to the pharmacy service or
pharmacist’s intervention
• CEA
―Number of orders or Rx changed due to pharmacist’s intervention
―Number of patients in control of symptom/disease after pharmacist’s intervention
• CUA
―Improvement in quality adjusted life years (QALYs) after pharmacist’s intervention
7
History of pharmacy services
8
History of pharmacy services
1971: Task Force on the Pharmacist’s Clinical Role identified the
need for research evaluating the effects of providing pharmacy
services (National Center for Health Services Research and Development)
1979: Bootman et al. published a CBA paper evaluating the value
of pharmacy services
―Most early studies were used to justify the value of providing ‘clinical
services’ such as pharmacokinetic dosing in the hospital setting
9
History of pharmacy services
1990: Hepler and Strand proposed the concept that pharmacists
should provide ‘pharmaceutical care’
―Pharmaceutical care is ‘the responsible provision of drug therapy for
the purpose of achieving definite outcomes that improve a patient’s
quality of life’
→Physicians provide medical care
→Nurses provide  nursing care
→Pharmacists provide  pharmaceutical care
10
History of pharmacy services
2006: MTM services was provided to high-risk patients as part of
the Medicare Part D outpatient prescription drug benefit which
took effect in January 2006
―This stemmed from the federal government’s recognition of the
importance of MTM services provided by pharmacists
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Trends of pharmacy services
research
The American College of Clinical Pharmacy (ACCP) Task
Force on Economic Evaluation of Clinical Pharmacy
Services
12
Trends of pharmacy services research
• Several publications on pharmacy services have emanated from
the American College of Clinical Pharmacy (ACCP) Task Force on
Economic Evaluation of Clinical Pharmacy Services
• The ACCP Task Force studies summarized the economic
literature on pharmacy services at different time points
1.
2.
3.
4.
5.
Willett et al., 1989 – studies before 1988
Schumock et al., 1996 – studies between 1988-1995
Schumock et al., 2003 – studies between 1996-2000
Perez et al., 2009 – studies between 2001-2005
Touchette et al., 2014 – studies between 2006-2010
13
Trends of pharmacy services research
• The ACCP Task Force studies contains tables that list each
study’s:
―Objective
―Methods
―Comparison group
―Input costs
―Outcomes measured
―Results
―Comments
14
ACCP Task Force Report, 2014
• Most recent ACCP Task Force study
―Conducted by Touchette et al., 2014
―Systematic literature review of studies evaluating clinical pharmacy
services published from all over the world between 2006-2010
• Objective: To describe and evaluate the quality of economic
evaluations of clinical pharmacy services (CPS) in order to help
inform administrators and practitioners as to their costeffectiveness
15
ACCP Task Force Report, 2014
• Study design
• n=3,587 potentially relevant papers from 2006-2010
• n=25 studies met inclusion criteria
―Exclusion criteria (n=3,562)
→Non-English manuscripts
→Not original work (reviews, editorials, report, meta-analysis)
→No clinical pharmacy service involved
→No economic analysis conducted
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ACCP Task Force Report, 2014
• What were the perspectives taken by studies analyzed?
―Health care payer (11 of 25 = 44%)
―Provider (11 of 25 = 44%)
―Two perspectives (2 of 25 = 8%)
―Patient (1 of 25 = 4%)
―Societal (0 of 25 = 0%)
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ACCP Task Force Report, 2014
• Study origin
―Europe (13 of 25 = 52%)
―United States (9 of 25 = 36%)
―Canada (2 of 25 = 8%)
―Australia (1 of 25 = 4%)
―Asia/Africa (0 of 25 = 0%)
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ACCP Task Force Report, 2014
• Clinical pharmacy service settings
―Hospital (36%)
―Community pharmacy (32%)
―Clinic or hospital-based outpatient pharmacy (28%)
―Long-term care facility (16%)
―Ambulatory care clinic (16%)
Note: Percent total is >100% because of multiple responses as some
studies evaluated clinical pharmacy services in more than one setting
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ACCP Task Force Report, 2014
• Clinical pharmacy service types
―Disease state management (48%)
→CPS primarily directed at patients with a specific disease state or diagnosis
―General pharmacotherapeutic monitoring (24%)
→CPS that encompasses a broad range of activities based primarily on the
needs of a specific clinic or panel of patients
―Target drug programs (8%)
―MTM (8%)
―Patient education (4%)
―Wellness program/immunization (4%)
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ACCP Task Force Report, 2014
• Economic analyses description
―Costs were evaluated in 24 studies (96%) and sufficiently described in
13 (52%)
―Clinical or humanistic outcomes (quality of life) were evaluated in 20
studies (80%) and were sufficiently described in 18 (72%)
―Eighteen studies (72%) involved full economic evaluation (i.e.,
simultaneous comparison of both costs and outcomes)
―Benefit/cost ratios from three studies ranged from 1.05/1 to 25.95/1
→Conclusion: Clinical pharmacy services were generally considered costeffective or provided a good benefit/cost ratio
21
Summary of specific, large
multisite pharmacy services
projects in the United States
The IMPROVE Study (Ellis, 2000; Carter, 2001)
The Ashville Project (Cranor, 2003; Bunting, 2006)
The Patient Self-Management Program (Garrett, 2005)
22
Multisite pharmacy services projects
• Economic results of some multisite outpatient pharmacy
service studies have been published, with varying results
• However, three large prospective studies with positive clinical
and economic findings include
1. The Impact of Managed Pharmaceutical Care on Resource
Utilization and Outcomes in Veterans Affairs Medical Centers
(IMPROVE) Study
2. The Ashville Project
3. The Patient Self-Management Program (PSMP)
23
The IMPROVE Study
• Objective: To assess the general health outcomes of Veteran Affairs (VA) patients
receiving care in ambulatory clinics
• Setting: 9 VA sites across the nation
• Subjects: VA patients at high risk for drug-related problems
• Intervention group: Pharmaceutical care service (PCS) + usual care (n=523)
―Patients were contacted by clinical pharmacists (n=78) for an average of three
times a year, for about 15 minutes each time
―PCS include medical conditions and drug-related problems addressed by
pharmacists
―Methods of PCS delivery: in-person contact (77%), telephone (23%)
• Control group: Usual care alone (n=531)
• Follow-up period: One year
24
The IMPROVE Study
• Results
―More drug-related problems were addressed and resolved when
visits were 15 minutes or longer (p=0.001) and when the contact was
in-person (p=0.001)
―There was improvement in glucose and cholesterol levels among the
intervention group
―Increase in cost of medical care over the follow-up period was lesser
for the intervention group ($1,020) compared to the control group
($1,313)
―However, there was no significant difference in HRQoL (using the SF36 survey) between the two groups
25
The Ashville Project
• Participants
―employees of the City of Ashville, NC
―employees of the Mission-St. Joseph’s (MSJ) Health System in Ashville, NC
• Target diseases
―Diabetes and asthma
• Intervention
―Consultations by pharmacists
→Medication review
→Medication monitoring
→Patient education
→Physical assessments
• Significant results (among intervention group)
―Improved blood glucose and asthma control
―Reduced direct medical costs
―Reduced indirect costs (reduced sick days)
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The Patient Self-Management Program (PSMP)
• Initiated due to the success of the Ashville project
• Settings
―Five communities in four different states
→Greensboro, NC; Wilson, NC; Dublin, GA; Manitowoc County, WI; and
Columbus, OH
―256 diabetes patients
• Intervention
―80 community pharmacists certified in diabetes services
→scheduled consultations
→clinical goal setting, monitoring, and collaborative drug therapy management
with physicians
→referrals to diabetes educators
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The Patient Self-Management Program (PSMP)
• Follow-up
―One year
• Outcomes measure and Results
―Improved A1C blood glucose (7.9 →7.1%)
―Improved LDL cholesterol levels (113.4 →104.5 mg/dL)
―Higher flu vaccination rate (52 →77%)
―Higher eye examination rate (46 →82%)
―Patient satisfaction with diabetes care (57 →95.6%)
―Reduction in health care costs ($918 lower than projected)
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Summary
1. CBA is the analysis most often used to evaluate pharmacy services;
however, CEA and CUA can also be used
2. The payer and provider perspectives are the most common
perspectives taken in pharmacy services research
3. Most pharmacy service studies are conducted in Europe
4. Pharmacy services are most commonly provided within the hospital
and community pharmacy settings
5. The clinical pharmacy service type most commonly provided is disease
management
6. In general, provision of clinical pharmacy services are considered cost
beneficial
29
References
1.
2.
3.
4.
5.
6.
7.
National Center for Health Services Research and Development. Report of the Task Force
on the pharmacist’s clinical role. J Am Pharm Assoc. 1971; 11(9):482-485
Bootman JL, Zaske DE, Wertheimer AI, Rowland C. Cost of individualizing aminoglycoside
dosage regimens. Am J Hosp Pharm. 1979 Mar;36(3):368-70
Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp
Pharm. 1990 Mar;47(3):533-43
Willett MS, Bertch KE, Rich DS, Ereshefsky L. Prospectus on the economic value of clinical
pharmacy services. A position statement of the American College of Clinical Pharmacy.
Pharmacotherapy. 1989;9(1):45-56
Schumock GT, Meek PD, Ploetz PA, Vermeulen LC. Economic evaluations of clinical
pharmacy services–1988-1995. The Publications Committee of the American College of
Clinical Pharmacy. Pharmacotherapy. 1996 Nov-Dec;16(6):1188-208
Schumock GT, Butler MG, Meek PD, Vermeulen LC, Arondekar BV, Bauman JL; 2002 Task
Force on Economic Evaluation of Clinical Pharmacy Services of the American College of
Clinical Pharmacy. Evidence of the economic benefit of clinical pharmacy services: 19962000. Pharmacotherapy. 2003 Jan;23(1):113-32
Perez A, Doloresco F, Hoffman JM, Meek PD, Touchette DR, Vermeulen LC, Schumock GT;
American College of Clinical Pharmacy.. ACCP: economic evaluations of clinical pharmacy
services: 2001-2005. Pharmacotherapy. 2009 Jan;29(1):128
30
References
9.
Touchette DR, Doloresco F, Suda KJ, Perez A, Turner S, Jalundhwala Y, Tangonan MC, Hoffman JM.
Economic evaluations of clinical pharmacy services: 2006-2010. Pharmacotherapy. 2014 Aug;34(8):77193
10. Ellis SL, Billups SJ, Malone DC, Carter BL, Covey D, Mason B, Jue S, Carmichael J, Guthrie K, Sintek CD,
Dombrowski R, Geraets DR, Amato M. Types of interventions made by clinical pharmacists in the
IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in
Veterans Affairs Medical Centers. Pharmacotherapy. 2000 Apr;20(4):429-35
11. Carter BL, Malone DC, Billups SJ, Valuck RJ, Barnette DJ, Sintek CD, Ellis S, Covey D, Mason B, Jue S,
Carmichael J, Guthrie K, Dombrowski R, Geraets DR, Amato M; Impact of Managed Pharmaceutical care
on resource utilization and Outcomes in Veterans affairs medical centers.. Interpreting the findings of
the IMPROVE study. Am J Health Syst Pharm. 2001 Jul 15;58(14):1330-7
12. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes
of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003 Mar-Apr;43(2):173-84
13. Garrett DG, Bluml BM. Patient self-management program for diabetes: first-year clinical, humanistic, and
economic outcomes. J Am Pharm Assoc (2003). 2005 Mar-Apr;45(2):130-7
14. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of
a community-based medication therapy management program for asthma. J Am Pharm Assoc (2003).
2006 Mar-Apr;46(2):133-47
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