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Ron Purkiss is clinical director at Sheffield Teaching
Hospitals NHS Foundation Trust |
Pharmacoeconomics is a relatively new branch of health economics. Economics
is about how we, individuals, society and governments, choose to use
fixed resources. Fixed resources can be, for example, time, effort, money,
machinery or buildings. Currently, the demand for health care cannot
be met with the resources individuals, society and governments are prepared
to allocate to it.
Health economics is a tool to help us prioritise different and sometimes
competing health care interventions for these fixed resources and, in
doing so, health care is treated as a commodity like any other. Unfortunately,
however, health care is not as simple as some other commodities and,
as we have observed recently in the case of Herceptin, politicians often
become involved in this decision-making process.
Pharmacoeconomics helps us to make decisions about the use of medicines.
Most pharmacoeconomic studies in health care are cost-effectiveness studies
set out to demonstrate how to achieve an objective with the least use
of resources. This should not be confused with efficiency, which measures
how well we use resources in order to obtain the desired outcome.
Other types of pharmacoeconomic analyses are cost minimisation analyses,
where two or more interventions having identical outcomes are evaluated
for the least cost for that outcome; cost utility analyses, where the
outcome is measured as a utility, such as quality of life; and cost-benefit
analyses, which involve the measurement of both tangible and intangible
values. Cost-benefit studies are difficult to design and the biggest
problem is quantifying benefits in financial terms. They are therefore
rarely used in a health care setting.
Pharmacoeconomics is used at all stages in the development of medicines
by the pharmaceutical industry, when medicines are researched, produced
and marketed. Some countries insist on pharmacoeconomic evaluations as
part of the licensing process. Most hospital pharmacists use pharmacoeconomics
to assist with making decisions involving formularies and how medicines
can be used in a more cost-effective or cost-beneficial manner.
However, differing methods of analysis can produce conflicting results.
An example is the recent National Institute for Health and Clinical Excellence
guidelines on the use of acetylcholinesterase inhibitors in Alzheimer’s
disease. NICE, using primary cost effectiveness analysis, saw little
value in using anticholinesterase inhibitors until the latter stages
of the disease. The Alzheimer’s Society submitted to NICE a survey
of almost 1,000 patients who had used donepezil, describing its benefits.
Although not a true cost-benefit analysis, patient groups, patients and
carers placed greater value on benefits perceived or otherwise in the
treatment of their elderly relatives or patients than NICE.
Pharmacist input
Knowledge of health economics coupled with political insight is essential
to understand resource allocation and expenditure in a modern health
care system. Pharmacists, with their unique knowledge of medicine, are
crucial in using pharmacoeconomic analysis to influence expenditure and
distribution of resources on medicines.
The basis of financing secondary care is currently changing. Under “payment
by results”, providers of care are paid for each patient spell
according to a national tariff, which is based on an national average
cost for a particular patient spell. As foundation trusts increase, the
number of hospitals that depend on tariff payments for their income also
grows. Therefore, using the most efficient methods of working to reduce
cost and maximize benefits is becoming increasingly important. Pharmacoeconomics
is part of the tool bag pharmacists can use to improve the efficiency
of their hospitals.
Politically, payment by results and practice-based commissioning are
key elements in the Government’s strategy to improve the efficiency
of the NHS. In theory, if hospitals improve their efficiency and deliver
increased activity the trust will make a profit, which should then be
invested in improving health care. In some medical disciplines the medicines
element to the overall tariff price can be considerable, and savings
on costs of medicines can make the difference between a profit or loss
for the trust. The application of pharmacoeconomics to improve the efficient
use of medicines is a key component in this productivity drive.
Medicines expenditure is a highly visible non-staff cost that is always
under scrutiny and is seen as an easy and non- controversial budget for
targeting. Pharmacists must have efficient, safe and reliable medicines
management systems in place and must be able to demonstrate this. Audits
of medicine use and clear decision-making processes using pharmacoeconomics
demonstrate good practice.
With every aspect of hospital life under scrutiny, pharmacy has become
more visible. Although the clinical role of the profession is appreciated,
it is the role of the pharmacist in advising on medicines expenditure
and ensuring economical use of medicines that has increased demand for
their services. In many directorates the only person with the required
knowledge, experience and expertise to manage the medicines budget is
the directorate pharmacist. Medicines management technicians are now
also seen as essential to the overall improvement in efficiency and reduction
on medicines expenditure.
Knowledge of health economics and application of its techniques is essential
to today’s pharmacist. |
Hospital Pharmacist