A review of the pharmacoeconomics of pharmaceutical care.

Numerous studies have demonstrated that the therapeutic use of drugs results in adverse outcomes and contributes to high rates of morbidity and mortality. The causes of drug-related problems are multifactorial and their assessment has been based on factors such as inappropriate prescribing, inappropriate delivery, inappropriate patient behaviour, patient idiosyncrasy and inappropriate monitoring. The cost in the ambulatory setting has been estimated to exceed total prescription pharmaceutical use. Pharmaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. It describes the process through which a pharmacist cooperates with a patient and other healthcare professionals in designing, implementing and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient. This article evaluates published studies related to the economic analysis of pharmaceutical care in enhancing the value of pharmaceuticals. While numerous descriptive articles exist, our review found no studies which met accepted pharmacoeconomic criteria. A small number of studies measured process variables and/or quality of life, but only one considered costs. Barriers to optimising the economic value of pharmaceutical care were also explored. Common methodological shortcomings indicated a need for improvement in future studies. There is little published research to date which demonstrates the pharmacoeconomic benefits of pharmaceutical care. Evidence does exist that clinical pharmacy services have positive economic benefits, and it is this evidence that, at present, supports the assertion that pharmaceutical care has potential to increase the value of pharmaceuticals in society by minimising drug-related morbidity and mortality. Thus, well conducted research is required to determine the economic impact of pharmaceutical care.

Treatment of urinary tract infection. Clinical and economic considerations.

The epidemiology, clinical manifestations, natural history and management of urinary tract infection (UTI) are briefly reviewed as background to the economic considerations of diagnosis and treatment. Specific pharmacoeconomic analyses, such as cost-effectiveness and cost-benefit analyses, of UTI are not available. Analysis of the direct costs of diagnosis and treatment reveal that laboratory costs comprise the largest proportion, followed by physician consultation and pharmaceutical costs, respectively. Antimicrobial treatment has focused on acquisition cost without due regard to costs associated with method of delivery (especially with parenteral therapy), drug monitoring, complications, suboptimal therapy, drug wastage and waste disposal. These factors indicate a preference for ambulatory therapy using oral antimicrobials rather than institutional care using parenteral agents. Indirect costs, such as lost work time and quality-of-life factors, are not readily available. Evidence suggests that nosocomial UTIs add significantly to hospital costs. Studies citing the cost effectiveness of infection control programmes have often lacked detail and may have accrued benefits to the service without apportioning full costs. Future research directions include analysis of laboratory economics in relation to the clinical encounter, improved analysis of the utility and total costs of newer antimicrobials, quantifying home versus hospital treatment and improved costing of infection control programmes.

Drug and therapeutics committees: the relationships among structure, function, and effectiveness.

Reported are the results of a national study of Australian hospitals that assessed the effectiveness of drug and therapeutics committees (DTCs), identifies factors that influence effectiveness, and recommends methods to improve effectiveness. Data were collected by questionnaires sent to 184 hospital directors of pharmacy and a subset of 53 chairpersons of DTCs. Response rates were 88.6% and 84.9%, respectively. Membership, chairperson, secretary, meeting frequency, and decision-making functions were analysed by hospital bed numbers and compared with standard accepted literature criteria and previous study findings. A comparison of pharmacist and chairperson perception as to the weakest aspect of DTCs in attaining rational therapy revealed widely differing views, based on factors outside respondents' own control. Perceptions of resources required to overcome DTC weakness also varied between the two groups. No statistically significant association was found between the assessment of outcome of DTC activities (influence on pharmacy management, hospital policy, medical management, and prescribing) and structural variables such as DTC objectives, chairperson, reporting relationship, meeting frequency, and hospital size or type. The results challenge widely held assumptions of the association between DTC effectiveness and structural variables. Further study of structural and cultural variables, which might determine effectiveness, is required.

Justification of a pharmacy intravenous admixture service in an Australian hospital.

The time and cost of i.v. admixture preparation by hospital pharmacy staff members in an established admixture unit was compared with that by nurses working on wards. The preparation time of antimicrobial admixtures was determined by using a stopwatch. The total cost of preparing an admixture by pharmacy and nursing staff was calculated by combining the respective labor costs (preparation time x average salary rates weighted for overtime) with the cost of disposable items. The mean +/- S.D. time for admixture preparation in the pharmacy was 3.38 +/- 0.38 minutes, whereas preparation by nurses required 14.37 +/- 1.55 minutes. The mean +/- S.D. total cost (in Australian dollars) of admixture preparation was $1.42 +/- 0.34 per dose, and $4.59 +/- 0.46 per dose, respectively. Centralization of admixture preparation would reduce the time required by 18.32 hours for every 100 admixtures prepared, equivalent to an annual cost avoidance of $112,420 for every 100 admixtures prepared each day. Centralizing the preparation of i.v. admixtures in a hospital pharmacy resulted in significant time savings and cost avoidance.

Comparative attitudes to verbal and written medication information among hospital outpatients.

This study was undertaken to assess the comparative preference of pharmacy outpatients for verbal and written medication information and to identify factors that might influence these preferences. Two hundred forty-seven consecutive, literate outpatients presenting with a prescription for a penicillin were enrolled in the study and given standardized verbal counseling by a pharmacist and a medication information leaflet. Assessment was made at initial presentation and by a prepaid mail questionnaire completed anonymously by the patient at home. Preferences were analyzed by age, sex, and number of medications prescribed. A response rate of 63 percent (155/247) was obtained. Low recall of physician instruction (11 percent) was recorded. Respondent preferences were for pharmacist counseling (30.4 percent), leaflet (20.6 percent), both of these (44.5 percent), or neither/uncertain (4.5 percent). The only factor having a statistically significant effect on these preferences was age (31-55 y), which influenced preference for a leaflet. Patient opinion of each leaflet section is presented. Patient preference for a leaflet or verbal counseling with a leaflet provides further evidence that leaflets should be widely used.

Cost comparison of intravenous antibiotic administration.

The cost of preparing and administering intravenous antibiotics in an Australian teaching hospital was determined. The costs associated with acquisition, delivery (administration system, ancillary equipment, labour), and laboratory monitoring for potential toxicity were calculated. Standard regimens based on antibiotic guidelines were used to compile the daily total cost. The results indicate that these components affect the daily total cost of individual antibiotics in different ways. Acquisition cost is often a poor predictor of total cost, which ranges from 1.2 times to almost eight times the acquisition cost. Less frequent administration reduces total costs substantially, as does slow injection compared with infusion. Laboratory costs constitute between 3.6% and 23% of the daily total cost and are most pronounced with antibiotics that have low acquisition costs. Antibiotic cost containment should not focus on acquisition cost alone. Daily total cost to administer antibiotics is a more appropriate and accurate costing method. Hospitals must acknowledge the need for innovative resource allocation methods which recognise this fact.

Drug bulletins: effectiveness in modifying prescribing and methods of improving impact.

Little research has been conducted into the impact of drug bulletins in modifying prescribing and containing costs. The authors review published reports of bulletin effectiveness in institutional and community settings, pointing out the apparent enhanced usefulness of drug bulletins combined with other informational strategies and products. They offer guidelines for boosting bulletin effectiveness through content and design of decisions.

Drug newsletters and quality assurance of drug usage.

The use of a drug newsletter publishing results of drug usage review studies, as a quality assurance measure aimed at improving drug prescribing in an Australian acute care hospital, is described. Drug usage review studies focus primarily on newly registered drugs, drugs with potential for misuse or adverse reactions, and expensive drugs. Data are collected on comprehensive data sheets by clinical pharmacists. Information is supplemented from relevant sources, including laboratory test results. Feedback to prescribers, through the hospital's drug newsletter, presents review results, evaluated by comparison with predetermined standards for appropriateness, together with recommendations for improvement, where indicated. The reviews have highlighted areas in which prescribing could be improved. Studies have shown that the drug newsletter has a significant, but possibly transient, impact on modifying prescribing patterns. Newsletter messages are therefore reinforced by personalized clinical pharmacist interaction with prescribers.

Improving patient care and pharmacy management: the effect of hospital formularies.

A study of the organizational features and implementation procedures associated with formulary use in major acute-care hospitals throughout Australia was undertaken. Data were collected via a questionnaire mailed to 57 directors of pharmacy. An 86-percent response was obtained. A high proportion of formularies was found to rate poorly in terms of organizational features (e.g., content, compilation methods, format) and process variables (e.g., effectiveness as a communication document, prescribing aid, or management tool). Methods of improving formulary effectiveness are outlined in the context of practical and normative research, including improving the quality of drug therapy, use of formularies in cost control, and improving user acceptance. The results confirm previous research showing that methods of improving organizational features and implementation procedures associated with formulary compilation and use are neither widely applied nor widely known. There is an urgent need to reassess the usefulness of formularies and improve their effectiveness by adopting recommendations resulting from past research.

Assuring rational antibiotic use: the impact of a joint microbiology-pharmacy surveillance program.

A comprehensive antibiotic surveillance program conducted in cooperation with the Microbiology and Pharmacy departments in a teaching hospital is described. The program consists of a number of interrelated processes including the personal advice of specialists including a Clinical Microbiologist, Infection Control Nurse and Ward Pharmacists, re-educative strategies and non restrictive administrative policies. The program does not involve the use of formularies or published guidelines, and retains complete clinical freedom of choice for antibiotics. Studies, including antibiotic prevalence and prescribing surveys, indicate that the program has been an effective means of improving antibiotic use, reducing costs and promoting infection control. This has been achieved by educative means through the provision of relevant information on antibiotic principles, and opportunities for prescribers to improve their problem solving skills, resulting in long term attitudinal change.

Change through continuing education: an unproven strategy.

Continuing education is the strategy most favoured to ensure professional competence and maintain standards of patient care. This paper questions the effectiveness of current continuing education programs with their emphasis on the structure and process of professional practice. Problems with assessment using course participants' views and the educational content of programs are examined. The assumptions that knowledge is translated into improved performance and that continuing education improves outcomes, notably patient care, are questioned. It is essential that continuing education be evaluated in terms of outcomes. Without a demonstrable improvement in the practical application of skills such programs cannot be viewed as cost effective.