economic and clinical pharmacy services [read-only]...1. define the problem and determine your...
TRANSCRIPT
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Economic Evaluations of Clinical Pharmacy Services 2001–2005
Fred Doloresco, PharmD, MS Clinical Assistant Professor
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Objectives
• Discuss literature examining the clinical and financial benefits of clinical pharmacy services.
• Identify opportunities for implementing financially viable clinical pharmacy services in multiple practice settings.
• Identify resources available to assist with the development of a business plan for clinical pharmacy services.
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Over the past 40 years there has been dramatic changes in the practice of pharmacy.Most notable is the transition from a product orientation to a patient orientation.◦ Clinical pharmacy services (1970s)◦ Consultant pharmacy services (1980s)◦ Pharmaceutical care (1990s)◦ Medication therapy management (2000s)◦ Medical home/patient-centered care (2010s)
Background
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• The value of the pharmacist in product-related functions has been closely tied to the price of the prescription.
• However, pharmacists clinical services have been more difficult to put value on. We believe that clinical pharmacy services can:• Improve outcomes.• Save money.• Make money (i.e., bill for clinical pharmacy
services, where applicable).
Background
Save moneyBill for CPS
Improve Outcomes
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• Value = Quality ÷ Cost• Where Quality = Outcomes• We can measure economic, clinical, or humanistic
outcomes (ECHO)
Thus, the value of clinical pharmacy is defined by ability to improve clinical, humanistic, and/or economic outcomes, given the cost to provide such services.
Value of Clinical Pharmacy Services
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How to Evaluate Value of CPS
Input OutputIntervention(CPS)
MeasurementCOSTSResources consumedCost of providing service“investment”
Units = $
CONSEQUENCES(outcomes, effect)
clinical outcomehumanistic outcomeeconomic outcome
Units = depends on outcome
Measurement
Input No intervention(control or comparator) Output
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• Cost-effectiveness• Compare average cost-effectiveness ratios ($C:E, e.g. cost per life
saved) or compute incremental cost-effectiveness ($C1-$C2)/(E1-E2).
• Cost-utility• Compare average cost-utility ratios ($C:U, e.g., cost per quality-
adjusted life year) or compute incremental cost-effectiveness ($C1-$C2)/(U1-U2).
• Cost-benefit• Compare average benefit-to-cost ratios ($B:$C, e.g. cost per dollar
invested) or compute incremental benefit-to-cost ($C1-$C2)/(B1-B2).
• Net benefit ($B-$C).• Return on investment ($B-$C)/($C).
Metrics
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Evidence from Literature
Economic
Clinical
Humanistic
ECHO Model =
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Literature
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Nkansah et al. Cochran Database Syst Rev 2010; 7.• Systematic review of studies investigating the health-
related outcomes of CPS. • Time-period: 1966-2007. • Pharmacist interventions resulted in improvement in
most clinical outcomes (not always statistically significant).
• Meta-analysis of studies measuring effect of CPS on BP: -6.32 mmHg/-3.12 mmHg (P<0.001).
• Meta-analysis of studies measuring effect of CPS on blood glucose: -0.75% HbA1c (P=0.03).
Clinical Outcomes of CPS
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Kaboli et al. Arch Intern Med 2006;166:955-64.• Systematic review of studies investigating the clinical
effectiveness of CPS in inpatient medical care. • Time-period: 1985-2005. • 36 studies included; evaluated medical rounds
participation, medication reconciliation, drug-specific services.
• Adverse drug events or medication errors reduced in 7 or 12, medication adherence improved in 7 of 11 studies.
Clinical Outcomes of CPS
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Pickard, Hung. Ann Pharmacother 2006; 40: 1623-34. • Systematic review of studies of the humanistic impact of
CPSTime period: Mar 1999-Dec 2004.Number of studies that evaluated HRQOL outcomes more than tripled.Study designs improved (longer length of follow-up and a wider breadth of CPS types).For certain services (asthma management) evidence of HRQOL benefit is most convincing.
Humanistic Outcomes of CPS
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Nkansah et al. Cochran Database Syst Rev 2010; 7.
• Systematic review of studies investigating the health-related outcomes of CPS.
• Time-period: 1966-2007. • 8 studies report QOL outcomes, 3
showed improvement in at least 3 sub-domains in patients with asthma and high risk medication-related problems.
Humanistic Outcomes of CPS
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• 1988-1995: Schumock GT, Meek PD, Ploetz PA, Vermeulen LC. Economic evaluations of clinical pharmacy services—1988–1995. Pharmacotherapy 1996;16:1188–208.
• 1996-2000: Schumock GT, Butler MG, Meek PD, Vermeulen LC, Arondekar BV, Bauman JL; Evidence of the economic benefit of clinical pharmacy services: 1996-2000. Pharmacotherapy. 2003;23(1):113-32.
• 2001-2005: Perez A, Doloresco F, Hoffman JM, Meek PD, Touchette D, Vermeulen LC, Schumock GT. Economic evaluations of clinical pharmacy services 2001-2005. Pharmacotherapy 2009;29(1):128.
Economic Outcomes of CPS
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• Quality and safety of medication therapy • Cost reduction (cost effectiveness)• Growing role of pharmacists (provider status)
• Medicare Prescription Drug Improvement and Modernization Act of 2003
• Healthcare reform• Development of Current Procedural Terminology
codes• Growing health care costs
• Importance of cost justification of CPS
Why are CPS important?
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Doloresco F, et al. Projecting Future Drug Expenditures – 2011. AJHP. Publication pending.
US
D (B
illio
ns)
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Clinical Outcomes of CPS (Inpatient)
Bond CA, Raehl CL, Patry RL. Pharmacotherapy 2004;24:427-440.
Admission Medication Histories
Medical Rounds Participation
Drug ProtocolManagement
ADR Management
Drug Information
Medication Errors
Length of Stay
Total Cost of Care
Drug Costs
Mortality Rate
?
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Importance of Continued Economic Evaluations
• Rise in pharmaceutical costs• Pharmacist salaries
• Evaluation of Medication Therapy Management programs (Medicare Part D)
• Effect of outpatient CPS in long-term outcomes
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Results
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Results→ 3793 hits
→ 3217 articles excluded after title review
→ 297 articles excluded through abstract review
→ 186 articles excluded after full review
→ 93 papers included→ 15 papers included in benefit:cost ratio calculation (Calculated by reviewers when data available)
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Economic Outcomes of CPS%
of S
tudi
es
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Economic Outcomes of CPS%
of S
tudi
es
General Pharmacotherapeutic Management
Target Drug Monitoring
Pharmacokinetics
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Study Perspective
Provider, 58%Payer, 24%
Various, 10%Societal, 4%
Unspecified, 4%
N=93
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Benefit:Cost Ratios (pooled)(Financial benefit per dollar invested, $benefit :$1 invested)
1988-1995N=7
1996-2000N=5
2001-2005N=15
Lowest 1.08:1 1.7:1 1:1
Highest 75.84:1 17.01:1 34.60:1
Median 4.09:1 4.68:1 4.81:1
Mean 16.70:1 5.54:1 8.00:1
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• CPS are likely to improve clinical and humanistic outcomes, particularly for certain services or diseases, effect size and statistical significance may depend on many factors.
• CPS likely to improve economic outcomes, reduce healthcare utilization, save money.
Summary: Clinical, Humanistic, Economic Outcomes of CPS
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Literature – Conclusion
• CPS continue to be economically viable• Pharmacist wages
• Although improvement has been observed:• Studies with more rigorous design need to be
conducted • Reporting of input costs is lacking
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Opportunities
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Considerations
• Some factors to consider (regardless of setting):• Patient population (which patients?)• Your organization’s focus and strategic initiatives• Overall feasibility• Evidence/experience to indicate the service works
• May want to consider evidence for effectiveness versus feasibility in your specific situation.
• Patient desires?
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Considerations
• Partnerships available
• Funding sources• Internal• Payers (Part D plans)
• Loans
• Grants
Who are the stakeholders?
What do they care about?
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Decision Matrix
HIGH Level of Evidence LOW
HIGH
Feasibility
LOW
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Practical Approaches to Justify CPS
• Possible strategies 1. Interpret/generalize from other studies2. Economic modeling/projection3. Prospective evaluation
• Advantages and disadvantages exist
More difficultLess difficult
Less reliable More reliable
1 2 3
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• Possible strategies 1. Interpret/generalize from other studies2. Economic modeling/projection3. Prospective evaluation
• Advantages and disadvantages exist
Practical Approaches to Justify CPS
More difficultLess difficult
Less reliable More reliable1 2 3
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Strategy 1: Generalize from published studies• Advantages
• Quick• Inexpensive • Peer reviewed• Variety of services and results • Information available before implementation
• Disadvantages• External validity• Study quality?• Available applicable studies?• Available studies may not be convincing to decision makers
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• Possible strategies 1. Interpret/generalize from other studies2. Economic modeling/projection3. Prospective evaluation
• Advantages and disadvantages exist
Practical Approaches to Justify CPS
More difficultLess difficult
Less reliable More reliable1 2 3
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Strategy 2: Modeling/Projection
• Combine evidence from literature with own internal estimates (costs)• Costs • Benefits (in financial terms, if possible)
• Determine when/if program will break even
• Incorporate sensitivity analysis in projections (what if…?)• Patients miss appointments• Pharmacist wage increases/other cost increases over time
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Advantages/Disadvantages
• Advantages• Inexpensive• Quick• Yields organization specific results• Sensitivity analysis can be used to confirm results• Data collection is unobtrusive• Can be conducted pre-implementation
• Disadvantages• Results depend on assumptions• Potential for bias• Decision makers may not accept results of projection
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• Possible strategies 1. Interpret/generalize from other studies2. Economic modeling/projection3. Prospective evaluation
• Advantages and disadvantages exist
Practical Approaches to Justify CPS
More difficultLess difficult
Less reliable More reliable1 2 3
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Strategy 3: Prospective Evaluation
• Implement program (perhaps on a trial basis)• Measure actual costs• Measure actual benefits• Compare to “no service” or next best opportunity
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Advantages/Disadvantages
• Advantages• Flexible • Organization specific data• High internal validity (when appropriately designed)• Reflects “usual care” or effectiveness• More likely to be accepted by decision makers
• Disadvantages• Expensive (time and money)• Design challenges (control/randomization may not be feasible)• Potential for selection bias• Need adequate sample size• Need resources and authorization to start
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• May be helpful to develop a business plan.• Includes financial analysis as well as other
considerations.
Business Planning for CPS
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PDCA
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Eleven Steps in Prospective Evaluation of CPS
1. Define the problem and determine your perspective2. State your specific objectives3. Design your intervention4. Identify the alternatives for evaluation5. Choose a study design6. Determine the cost and consequences of interest7. Implement, measure the costs and consequences8. Analyze the data9. Summarize the data and present the results10. Decide on implementation11. Follow-up analysis
P
DC
A
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Stakeholders
• Who are the stakeholders?• What motivates them?
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Stakeholders in Different Settings
• The “Ps”• Patients• Prescribers• Pharmacists• Payers• “Penny pinchers”• Policy makers
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Possible Motivators
•Patients•Health/quality of life improvement•Out of pocket savings•Convenience•Specific goals
•Prescribers•Patient outcomes
• Clinical• Satisfaction
•Throughput• Billing
•Quality of care• Guidelines
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Possible Motivators
• Pharmacists• Patient outcomes
• Clinical• Satisfaction
• Financial• Job satisfaction
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Possible Motivators
•Payers•Patient outcomes
• Clinical• Satisfaction
•External reporting• NCQA/HEDIS
•Financial
•“Penny Pinchers”•Financial
• Cost-saving• Revenue producing• Market share
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NCQA and HEDIS
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Possible Motivators
• Policy makers• Who are they?
• “Boss” or payers• CEO, Director, etc.
• Revenue versus cost-saving• Quality
• Patient outcomes – satisfaction• Accreditation• Core measures (hospitalcompare.gov)
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Hospital Compare Core Measures
• The hospital process of care measures include: • 7 - heart attack care • 4 - heart failure care • 6 - pneumonia care • 8 - surgical care improvement project • 3 - asthma care for children only
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Generated via www.hospitalcompare.gov
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Top Hospital Lists
• Thompson-Reuters• http://www.100tophospitals.com/
• US-News and World Reports• http://health.usnews.com/best-hospitals
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US News and World Reports
From http://health.usnews.com/best-hospitals
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Side Note: Process versus Outcomes
• Some quality scoring systems look at process, outcomes, or both• Process – Measures desirable actions
• % of patients on a beta-antagonist post-MI
• Outcome – measures desirable outcomes• 30-day readmission rate
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Quality reporting is nice, but…
• What argument can I build around it?• Inpatient setting
• “Never events”• Financial benefit of reporting
• Hospitals docked 2% of CMS reimbursement• The future: Top/bottom hospital reimbursement
changes?• Payer
• NCQA accreditation• Community
• PQA – MPR and gaps in coverage for specific medications
http://www.pqaalliance.org/measures.htm
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Resources for Business Plans
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• Find articles similar to the service you want to offer:• Perez A, et al. ACCP White Paper: Economic
Evaluations of Clinical Pharmacy Services 2001 –2005. Pharmacotherapy. 2008;28:285e-323e
• Business plan resources• Harris IM et al. Developing a Business-Practice
Model for Pharmacy Services in Ambulatory Settings. Pharmacotherapy 2008;28(2):7e–34e.
• How to Develop a Business Plan for Pharmacy Services. Glen T. Schumock and JoAnn Stubbings; 2007; ISBN:978-1-932658-57-6; ACCP Product Code: PD_01HDBP
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Conclusions
• Clinical pharmacy services provide value• Cost-reducing or revenue generating
• Median of > $4 per $1 invested• Next review expected to be published late 2011
• Justification and business plan presentations should focus on benefits that will appeal to the decision-makers
• Resources are available to assist with developing the business plan and proposal
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Questions?