Saturday, 7 January 2012

Cost/effect evaluation in pharmaceutical care

The development of a set of of indicators that enable the evaluation of expenditure in pharmaceutical care is pivotal to the local state funded healthcare system. The considerable rise in expenditure observed in the last 10 years or so cannot simply be attributed to demographic shifts or an increase in non-communicable disease, even though these two factors have contributed somewhat to exacerbate the situation. Without a comprehensive set of comparator milestones, administrators are served a poisoned chalice, only able to state their expenditure, having no standard set of outcomes measures against which to grade potential system improvements, or extract cost/effect ratios.

Continous increases in expenditure are coupled with budgetary considerations, which are all the more relevant in current times. Fiscal caution and a healthy respect for the value of monies invested and spent has taken over the general public consciousness; as often is the case with human nature, this was a result of the 2008 financial crash and the rude awakening that followed, rather than a self applied act of regulation. The need for all of humanity to exercise restraint and judgment with respect such matters was long overdue, and this has now spilt over into the world of healthcare administration, with the Maltese Islands being no exception.

The greatest obstacle encountered when considering the above subject is the fact that no hard and fast indicators for the cost/effect of pharmaceutical expenditure exist. A direct result of pharmaceutical expenditure is the provision of pharmaceutical care, as defined in the classical manner by Hepler and Strand; if this definition is to be taken literally, problems immediately arise. Very few countries have integrated the principles of pharmaceutical care fully into the fabric of their healthcare systems; the reasons for this are many, but include a lack of funding to implement the required changes to intervention procedures, a lack of healthcare professionals trained in such practice, and a lack of political and administrative will to push through with the reform necessary. This in itself is the first hurdle that must be overcome, especially when one begins to consider the local case. Pharmaceutical care forms a central part of the training of pharmacists within the curriculum of the pharmacy department at the University of Malta, however it has yet to be introduced in a full-scale scenario at Mater Dei General and also integrated into the system for the provision of medicines through the state-funded framework.

Quite likely, one would have to consider a batch of surrogate markers or end-points instead; the obvious and reasonable objection to such an approach would be that of proving causality, since a link between expenditure in one area and a related change in a health outcome might not necessarily mean that the first was the reason for a change in the latter, even though the two would be correlated.

An ideal scenario would be one where the possibility of a clean slate existed, and one would be able to start afresh, implementing a holistic treatment and outcome evaluation paradigm. This, however, is a Utopian pipe-dream, as reality is somewhat more complex and fraught with complexity. Without delving into the administrative and political intricacies that are necessary sequelae of such a movement of change, primary emphasis must be placed on the training of the instigators of such change. Focus must be initially concentrated on the principles to be adopted and engraved into the DNA of the health professionals involved; without a change in the mindset of the innovators and their interdisciplinary team nothing worthwhile can be achieved within a relatively short time frame. In the absence of this, we would have to settle for incremental change, which would no yield temporally beneficial results to the citizens of the Maltese Islands.

Thus the first steps to be taken are the training of more dedicated and specialized pharmacoeconomic personnel, with the remit of the development, refinement and application of pharmaceutical care indicators. This would enable us to obtain a clear picture of the current efficiency of pharmaceutical financing and permit the framing of more cost-effective constructs, which as I stated earlier, is all the more relevant in the financial climate that governs our times.

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