At a forum at the International Pharmaceutical Federation’s congress in Vienna on August 30, participants learnt of the intermediate results of two projects, co-ordinated by teams from the United States and the Netherlands, to determine the added value of the pharmacist.
Professor ABraHAm Hartzema (University of North Carolina, United States) described
the intermediate results of his project, the aim of which was to demonstrate
the contribution pharmacists made to health care, both with respect to the health
improvement of the patients and the reduction in costs for health care systems.
He began by quoting from a 1999 report from the US Institute of Medicine. It
had said: “Health care is a decade or more behind other high-risk industries
in its attention to basic patient safety. More people die in medical errors
than from motor accidents, AIDS or breast cancer. Effective quality improvement
of health care requires a systems approach.”
Although performance-based review systems were used in the US to allow consumers
to compare hospitals and other health care services, no one had developed a
good set of indicators to compare individual pharmacy performance, said Mr Hartzema.
Since a report in the New England Journal of Medicine had stated that “regular
use of beta-agonists is associated with 2.6 times higher risk of deaths or near
deaths”, and with asthma in the US costing around $14.5bn, Professor Hartzema’s
project group had decided to concentrate their efforts on developing process
measures for asthma management which would then lead to performance measures.
The study had taken place in two phases, both looking at retrospective data.
The first phase had been conducted at prescription level and the second phase
at patient level. The indicator of choice had been mistimed prescription refills.
The pharmacies they had recruited were randomised and data collection was performed
over six months to ensure consistency. From the first phase, 38 per cent of
patients refilled prescriptions for inhalers too early. In the second phase,
4.8 per cent of patients were found to be in the high-risk category (high risk
being defined as patients filling more than six inhalers in one month). The
third indicator was designated as the number of patients refilling at least
two prescriptions for that inhaler within a month. Fifty-five to 56 per cent
of refills were early and 11 per cent were refilled within six days. These results,
together projected hospital admissions, translated into a proposed economical
value of $30,000. The limitations of the study were reported as patients not
using the same pharmacy regularly, the observation period being too short to
establish consistent over-use of inhalers, the sample size of patients being
too small to undertake a statistical analysis for significance, and the inability
of the method to investigate rapid asthma deterioration.
Professor Hartzema concluded that it was possible to develop quantitative process
measures for pharmacies which were shown to be consistent over time but the
work still needed to be validated. “Drug-related morbidity is highly prevalent
and has a great economic impact on society.” He urged pharmacists to become
more involved in developing performance indicators and warned that future reimbursement
would be performance-based.
The next stage of Professor Hartzema’s project would require the recruitment
of 12 to 20 countries each selecting 10 to 20 pharmacies over a two-year period.
It was planned that at the next FIP congress in Singapore in 2001, country co-ordinators
for training and data collection would be appointed. The final report of the
project would be given at the Sydney congress in 2003.
Mr Peter De Smet (the Netherlands) said it was important to realise that co-medication
and patient factors, eg, age, had an influence and the project team was concentrating
on an inappropriate indicator to discover problem areas. The Netherlands had
developed 12 indicators so far and had fed back these problem areas to their
pharmacists. This approach could help to identify problem areas but there was
no correlation between what was perceived as a problem and what actually happened
in reality. “Talking to patients is the conclusive thing,” he said.
Professor Hartzema replied that he appreciated that there were a lot of limitations
to the project but they were only just starting off.
Mr Almut Winterstein (US), a project team member, replied that they had had
to make a trade-off between long-term data collection and picking up enough
specific and sensitive data. Looking at two early refills was a better way of
doing this.
Ms Ingrid Schubert (Germany) wanted to learn about the practice variations and
whether it triggered an improvement in practice in their sample pharmacists.
Professor Hartzema replied that the project had been designed to help pharmacists
learn about their own practice. He emphasised that benchmarking should be done
by the profession and not by outsiders. “Let us keep the control in our
own hands,” he urged.