Outcomes Measurement: the ECHO Model

I. Outcomes Measurement: the ECHO Model 1 Learning Objectives • Outline the similarities and differences between outcomes research and pharmacoeconomic (PE) research • Describe the components of clinical decision making using the economic, clinical, and humanistic outcomes (ECHO) model • Describe how economic, clinical, and humanistic outcomes are measured 2 Defining Outcomes Research • Outcomes research is more broadly defined as “studies that attempt to identify, measure, and At evaluate the end results of health care services” • End results also include effects that people experience and care about such as improved ability to function (e.g., activities of daily living) or an increased quality of life • Not only clinical outcomes are measured, but also D economic and humanistic outcomes I 2 Bungay, K. M., & Sanchez, L. A. (n.d.). Types of economic and Humanistic Outcomes Assessments. American College of Clinical Pharmacy. https://www.accp.com/docs/products/ppc11/pharmacoeconomics.pdf 3 Examples of Health Outcomes • Physiologic measure (e.g., blood pressure, A1C) • Clinical events (e.g., stroke, myocardial infarction) • Mortality (e.g., infant mortality rate) • Symptoms (e.g., difficulty breathing) • Quality of life (e.g., HRQoL using SF-36) • Patient’s experiences with care (e.g., Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey) 4 Differences between PE and Outcomes Research • Pharmacoeconomics: the description and analysis of the cost and consequences of A pharmaceuticals and pharmaceutical services, and its effects on individuals, health care systems, and society - • PE is a type of “outcomes research” AA • However, not all outcomes research are PE research 5 The ECHO Model Economic Clinical Humanistic Outcome Bungay KM and Sanchez LA. Types of economic and humanistic outcomes assessments. ACCP Updates in Therapeutics: The ambulatory care pharmacy preparatory review and recertification course. ACCP. 2013; 2:509 -557. 6 The ECHO Model: Introduction can have studies they overlap • The evaluation of drug therapy and related services should include an assessment of the economic, clinical, and humanistic outcomes (ECHO) model I Treatment effectiveness wr 3 M Cost direct or Non siret last messag us S M 2 Quality of life Functional status Pam a surening 7 Dimensions of Outcomes • Economic outcomes money • Direct, indirect, and intangible costs as well as the consequences of medical treatment • Clinical outcomes All or BP • Medical events that occur as a result of disease or treatment • Humanistic outcomes quality of live • Consequences of disease or treatment on patients’ functional status or quality of life, measured along several dimensions 8 The ECHO Model (Conceptual) Humanistic Intermediaries Disease Clinical Indicators Measurements of a patient’s physical and biological status used to infer the severity or risk of disease (e.g., FEV, wheezing, breathlessness) Clinical Outcomes Costs Factors that alter outcomes associated with treatment alternatives (e.g., compliance with therapy, dosage forms) External Controls Functional status, QOL (e.g., physical function, social function, pain, vitality) Medical events that occur as a result of disease or treatment (e.g., asthma attacks, ER visits, hospitalization Treatment Modifiers Non-clinical factors that affect availability or use of treatment alternatives (e.g., formularies, prior authorization) Humanistic Outcomes Effects of disease and treatment on humanistic outcomes (e.g., side effects, satisfaction with therapy) Treatment Alternatives (e.g., beta-agonist vs. theophylline) Direct medical, direct nonmedical, indirect, and intangible costs Economic Outcomes Total costs of medical care associated with treatment alternatives balanced against clinical or humanistic outcomes(e.g., cost/QALY, cost/successful treatment) Kozma CM, Reeder CE, Schulz RM. Economic, clinical, and humanistic outcomes: a planning model for pharmacoeconomic research. Clin Ther. 1993;15(6):1121-1132. 9 Outcomes Measurements Velentgas P, Dreyer NA, Wu AW. Outcome definition and measurement. In: Velentgas P, Dreyer NA, Nourjah P, et al., eds. Developing a Protocol for Observational Comparative Effectiveness Research: A User’s Guide. AHRQ Publication 10 No. 12(13)-EHC099. Rockville, MD: Agency for Healthcare Research and Quality; January 2013: Chapter 6, pp. 71 -92. Measurement of Economic Outcomes A • This type of outcomes includes various cost A components such as direct costs (medical and non- medical), indirect costs, and intangible costs • They are usually of primary interest to the payer Payers cure how • Economic outcomes often are measured from payer they by and societal perspectives • Measuring economic outcomes often includes measures of health resource utilization much • number of inpatient or outpatient visits 2 • total days of hospitalization in a given year 3• number of days patients received a medication I 11 Measurement of Clinical Outcomes • Clinical outcomes often involve a diagnosis or assessment by a health care provider cimical every • They may be recorded in a patient’s medical record, as part of the electronic health record (EHR) or administrative billing system • They could be a clinical event, a diagnosis, or a lab result • Four categories of clinical outcomes are identified: - • • • 2• & Z Objective outcomes Subjective outcomes Composite endpoints/outcomes Intermediate endpoints/outcomes 12 Objective Outcomes reliable measured not subject to a large degree of As • Measures individual interpretation everyone - pretty clear to • Likely to be reliably measured across patients in a study, by different health care providers, and over time Clinical Diagnosis Objective measure Diabetes A1C, FPG Hypertension Blood pressure (mmHg) Myocardial infarction Troponin levels, ST elevation/depression Asthma Spirometry- Forced Expiratory Volume 1 (FEV1) 13 Subjective Outcomes • Outcome measures that are subject to interpretation and may not be reliably measured across patients by different care providers over certure numbers time not that clear • Examples include assessments of depression, sale it differently pain, or anxiety each person • Instruments have been developed to help standardize the assessment of some conditions not - on - I • To minimize subjective clinical assessments and unwanted variability • This helps produce a quantifiable measure that could be reproducible across patients and raters standardized scale level/ suds times a bot so see in the Son satutores as levels everyone levels can 14 7-10 Types of Subjective Outcomes or can't evaluate Pain & Satisfaction level Patient-reported outcome (PRO) Observer-reported outcome (ObsRO) Clinician-reported outcome (ClinRO) A measurement based on a report that comes directly from the patient about the status or events related to a patient’s health condition An assessment that is determined by an observer who does not have a background of professional training that is relevant to the measurement being made An assessment that is determined by an observer with some recognized professional training that is relevant to the measurement being made Parent are given reacher whep patself Can't report like Mind 15 Composite Endpoints • An outcome that comprises of series of individual clinical outcomes/events • Composite endpoints are often used when the individual events included in the score are rare, and/or when it makes clinical sense to group rure events so we put then together them • Example: MACE (major adverse cardiac events) j My Includes all oulcones hearratten th secure forether 16 SE-sarefte and effectiveness Composite Endpoints (Cont.) * can be differently dered in different studies • Varying definitions of composite endpoints could lead to substantially different results and conclusions. They could also prevent cross-study comparisons. • A study may define MACE as only related to safety (i.e., composite of death, MI, and stent thrombosis (ST)) • Another study may define MACE as related to both safety and effectiveness (i.e., composite of death, MI, ST, and either (1) target vessel revascularization (TVR) or (2) any repeat vascularization) Disatrame • Results from studies using composite endpoints must also be carefully interpreted, especially in the case where safety and effectiveness endpoints are * combined. antiplates refications for mase buy mas · - can be different in each staty 17 faces shorter Hire Intermediate Endpoints AS• Often are biological markers for the condition of interest A A • Also called surrogate endpoints • Common in clinical trials • Their use may reduce the follow-up period required to obtain results from a study of treatment effectiveness Clinical Trial for Statin Efficacy Main clinical outcome Coronary heart disease incidence Cardiac mortality takes long time Intermediate endpoint Serum lipids (LDL-cholesterol) takes look for something speel short the 18 : refective zefreti Intermediate Endpoints (2) • Two factors to consider when using intermediate endpoints: 1. Degree to which the intermediate endpoint is the reflective of the main outcome are they measuring some thing ? 2. Degree to which effects of the intervention may be mediated through the intermediate if effects and not endpoint Internestate getprint - sirechy Met Treatment 6 > - main true then not dustry we are really measuring main our cone 19 Sfir Q50 Patient gives their Measurement of Humanistic Outcomes • They are of primary interest to the patients • Differentiated by two characteristics: • They are clinically meaningful with practical implications for disease recognition and management • The reporting of outcomes is based on a patient’s unique perspective Parent gives it • Examples: HRQoL, patient satisfaction • Humanistic outcomes can be measured using outcomes (PROs) instruments A patient-reported this * know 20 Patient-Reported Outcomes (PROs) • Include any outcomes that are based on data provided by patients or by people who can report on their behalf (proxies) they submit survey for theserves • The FDA defines a PRO as “a measurement based on a report that comes directly from the patient (i.e., study subject) about the status of a patient’s health condition without amendment or interpretation of the patient’s response by a clinician or anyone else” ay feed Jack doesn't get • PROs can be measured by • self-report or • interview where the interviewer records only the patient’s response 21 List of PROs * Clinical not always outines humansiti onl come • Patient ratings and reports about the following outcomes: Health status Health related quality of life (HRQoL) Quality of life (QoL), defined more broadly Symptoms Functioning Satisfaction with care/treatment Health behaviors, including adherence and health habits • Health care utilization and out-of-pocket costs • I • It • A• It • It • It• * E 22 Summary • Pharmacoeconomics is a type of outcomes research; not all outcomes research is PE research • The ECHO model helps conceptualize all relevant outcomes when evaluating a drug therapy or intervention • Economic outcomes include direct, indirect, and intangible costs resulting from clinical and humanistic outcomes • Clinical outcomes refer to medical events that occur due to a disease or treatment • objective outcomes, subjective outcomes, composite endpoints, and intermediate endpoints • Humanistic outcomes are based on patient’s unique perspective and often related to patients’ functional status or quality of life 23 II. Retrospective Databases Rascati K.L. (2021). Chapter 11, Real-world Data/Real-world Evidence. Essentials of Pharmacoeconomics: Health Economics and Outcomes Research, 3e. Wolters Kluwer. 24 Learning Objectives • Describe the types of retrospective databases available for outcomes research • Give examples of retrospective databases • Explain the pros and cons for each type of databases • Explain additional issues to be addressed when critiquing research that uses retrospective databases 25 Types of Retrospective Databases Electronic Health Records (EHRs) Insurance Claims Records National Health Surveys 26 in general I Electronic Health Records (EHRs) or everyt to • EHRs are medical records that are transcribed into a database and can be accessed throughout der de sure a healthcare system A • Some people use EMR and EHR interchangeably • Electronic medical record (EMR) for oneClMi) - • Digital version of the paper charts in the clinician’s office • Contains the treatment and medical history of the patients in one practice AA-Emm one the visit • The information is not usually used outside At can't be shared 27 see Electronic Health Records (EHRs) • EHR contains information from all aspects of a patient’s care, such as • • • • • • Primary care physician visits Specialists Patient health history Diagnoses by other providers Lab results (blood, x-rays, MRI) Prescription refill records • EHRs go beyond standard clinical data collected in one provider’s office and focus on the total health ofAt the patient everything you need forear about a patios Ab • They are built to share information with other health care providers Pharmaly can see what curses or doctors 511 28 Advantages of EHRs Continuity of Care • Offer a rich source of data for PE research • Provide detailed information about patient encounters and patient data - good for reseach • Often there is information on some variables which insurance claims data lack, such as lab results, demographics, and family history • Promote the continuity of care • Compared to paper medical records, EHRs make it easier for the healthcare team to follow up with better tra Paper patients • EHR could have built-in reminder functions - 29 Disadvantages of EHRs expensing long on will refuce cos • EHRs are costly to implement initially • It could be time-consuming to retrieve information needed for a study takes - lot a of time 1 : 2 . expensive in the begging Long time & 30 Electronic Health Records (EHRs) Insurance Claims Records National Health Surveys 31 Insurance Claims Records • Insurance records are also called claims data At by insurance • Used for reimbursement purpose for the company for products and/or services provided by the retuous may pureuse not healthcare providers research • Claims data from different services and settings are merged to indicate patients’ overall medical utilization sith Person Put were insurance (to see often they use medical • May be collected by private insurers (Aetna, Blue Cross Blue Shield) or by public insurers (Medicaid, Department of Defense, VA) how *At for revonsment not research 32 Insurance Claims Records • Advantages • Large amount of patient data available in an easily good economical retrievable format retreat easy • The costs of setting up the database have already been financed -chea • Most data collected are reliable because they are used for adjudication of services delivered reliably so · - • Disadvantages • Often miss important information that may be needed to answer the research question (e.g., lab results, family history, HRQoL data) -not for research purpu far relupuesment • The changes in insurance eligibility make it difficult to track patient’s health changes or medical utilization Part time to full patterns over time lose Him, jor or - So not illegable for incurrence w ent so to trace over pre 33 for research I Electronic Health Records (EHRs) for remurswes Insurance Claims Records National Health Surveys 34 National Health Surveys • National health surveys collect information from a sample that is representative of the US population to answer key questions of interest to health care policy makers, public health professionals, and researchers represent us Population • National health surveys are conducted by various agencies mar ver • National Center for Health Statistics (NCHS) 3 • Agency for Healthcare Research and Quality (AHRQ) 3 • Health Resources and Services Administration I HRSA 35 National Health Surveys (Cont.) • Purposes of national health surveys include • Patterns of medical utilization in the United States Patter etrench • Factors that influence the use of health care resources • Factors influencing quality of health care, including safety • Disparities in health care services provided to population subgroups in the United States 36 Examples of National Health Surveys (1) • National Ambulatory Medical Care Survey (NAMCS) physician office • collects data about medical services provided to patients in office-based health care settings and health centers sierm - - rese • National Hospital Ambulatory Medical Care Survey (NHAMCS) hospital at our fassent • collected data about medical services provided in hospital emergency and outpatient departments as well as hospital-based ambulatory surgery centers • Final data were collected in 2022 https://www.cdc.gov/nchs/namcs/about/index.html https://www.cdc.gov/nchs/nhamcs/about/index.html 37 Examples of National Health Surveys (2) • National Health and Nutrition Examination Survey (NHANES) • A population-based survey that provides important health and nutritionalstatus information on adults and children living in the US only one incluses health young ad • The only national health survey includes health -AS At Ta exams and lab tests • Each year, about 5,000 adults and children in communities across the US participate in NHANES • It combines interviews, health exams, lab tests, and I DAA dietary interviews people themselves from A sooo https://www.cdc.gov/nchs/nhanes/index.html represent the us 38 Examples of National Health fory freed Surveys (3) every year !!! good one to inversar live reef at some most ↑ alot since aloo live • Medical Expenditure Panel Survey (MEPS) • National survey that produces estimates of health care use and expenditures for non-institutionalized mens live in committ civilians living in the US • It includes three separate but related component surveys 1. Household component survey 2. Medical provider component survey answered by 3. Insurance Component Survey • Also includes questions from the Short-Form (SF)-12 AA A and EuroQol (EQ)-5D to evaluate patient’s health status Physical - https://www.meps.ahrq.gov/mepsweb/ 39 National Health Surveys: Advantages for good sale researchers • Provide high-quality information on health care On utilization and health care costs high quality 1 UfTiz (u)7 • Results are generally representative of the US population represent americans : : : 2 - • MEPS data are obtained from a sample that represents noninstitutionalized civilians in the US 40 National Health Surveys: Disadvantages CumPRY Missing accurate • Some variables of interest (e.g., patient copayments or deductibles) may be missing • Data collected for some medical services may be more accurate than others repents of jeta sources • Analysis of survey data may be challenging due to the complexity of the sampling technique utilized big Scale of people - - geographic ↓ missing variables accurate the others . 2 sont more 3 ComplexChryscale . of People) 41 *A Registries - fr cacer or He • A collection of information about individuals who has a specific diagnosis or condition • Individuals provide information about themselves on a voluntary basis • Provide first-hand information about people with certain conditions • Be used to track trends about the number of people with diseases and treatments • Sponsored by a government agency, nonprofit -organization or private company • Example: Surveillance, Epidemiology, and End Results (SEER) program collects data from population-based cancer registries At 42 Critiquing PE Studies based on Retrospective Databases 43 Issues to be Considered 1. Was there a clear explanation of the database? 2. Was there a clear explanation of the patient selection criteria? 3. Was the insurance eligibility of patients described? 4. Were the clinical or outcome measures described? 5. Were sensitivity analyses conducted? 44 1. Explanation of the Database • Researchers should address the following: • The type of information available in the database(s) o years sear aro • For what period of time the data were collected • The population covered by the database(s) • VA (older men) • Medicaid (low-income) • Any formulary or payment restrictions specific to the insurance plan ↑ can go our of pogret out may not • Maximum number of prescriptions the plan will pay for each month be replete • Formulary medications chosen by the plan as being preferred 45 2. Explanation of Patient Selection Criteria inclusion any exclusion • Researchers should clearly explain the criteria used to select patients for the study • This refers to both inclusion and exclusion criteria • Age (e.g., only 18 years and above were included in the study) • Comorbid diagnoses • Concomitant medications • Proxies (such as medication use) to infer that patients had a disease • ICD-9-CM diagnosis codes 46 3. Insurance Eligibility of Patients • The insurance eligibility for some patients could seurance Plan change during the study period differe will - If hert missing • Switching to another insurance plan Inomaten • No longer working full time for their current employer • No longer meeting the criteria for receiving Medicaid • Need to describe how this issue is addressed • Gaps in insurance eligibility mean that patients’ utilization of medical/prescription services are not fully recorded or captured over the study period • Often, ineligibility at any time during the study period is considered as an exclusion criterion 47 4. Clinical or Outcome Measures • Certain patient outcome variables may not be included in medical claims databases -coravaikly • Clinical outcomes sometimes are inferred by using information from billed medical services Outcome of interest • Disease under controlled (yes/no) Clinical outcomes measures • HbA1C • Fasting plasma glucose Billed services markers • Diagnosis of ketoacidosis • Diabetes-related ED visit/hospitalization • These markers may not be as accurate as clinical outcomes and may be skewed by other patient factors me stuff we corset be not accurate osher 48 5. Sensitivity Analyses • Retrospective databases allow researchers to be flexible in selecting study design parameters • During sensitivity analyses, impacts on study results are examined by varying important study variables whet pic • Researchers can alter very easy to adjust andwat You • patient inclusion and exclusion criteria • length of follow-up period Matching grout • retrospective matching techniques • Sensitivity analysis also can be used to confirm whether a medication or service is specifically related to the disease of interest is it for speche a usert 49 Summary • Types of retrospective databases include: • Electronic health records (EHRs): they provide detailed information about patient encounters and patient data but may be time-consuming to analyze • Insurance claims records: essential for PE research; however, there may be missing variables because data are collected mainly for reimbursement purposes • National health surveys: information is collected from a sample that is representative of the US population; they help answer key questions of interest to health care policy makers, public health professionals, and researchers • Additional issues must be addressed when evaluating studies that use retrospective databases 50 III. Pharmacy Services Rascati K.L. (2021). Chapter 13, Pharmacy Services. Essentials of Pharmacoeconomics: Health Economics and Outcomes Research, 3e. Wolters Kluwer. 51 Learning Objectives • Discuss the history and development of research on the value of pharmacy services • Understand the importance of measuring costs and patient outcomes associated with MTM services • List issues specifically related to critiquing pharmacy service research 52 Defining Pharmacy Services Pharmalist is the player the provide • Pharmacy services consist of a variety of functions performed by a pharmacistAAA that may or may not be associated with dispensing a particular prescription order • Examples of pharmacy services include: - At D rest [ • Pharmacokinetic monitoring monitoring • Patient education to improve medication taking behaviors Patient education • Drug utilization review (DUR) owny revein 53 Defining Pharmacy Services (Cont.) all types of services • Other terms associated with pharmacy services: • • • • • Pharmaceutical care services Medication therapy management (MTM) Clinical pharmacy services (CPS) Cognitive pharmacy services Disease-state management 54 Defining Pharmacoeconomics At • Identification, measurement, and comparison of * the costs and consequences of pharmaceutical products and services Pharmacy services Pharmacoeconomics 55 Measuring Pharmacoeconomic Outcomes in Pharmacy Services Study type CBA O - Outcome examples Direct benefits, indirect benefits (via human mostcommencapital method), and intangible benefits (via uset willingness to pay methods) AAA **Outcome or benefit = amount of dollars saved due to the pharmacy service CEA # of orders or medications changed # of patients in control of symptom/disease CUA Improvement in quality adjusted life years (QALYs) T consequences 56 History of Pharmacy Services (1) • 1971: Task Force on the Pharmacist’s Clinical Role identified the need for research evaluating the effects of providing pharmacy services • 1979: Bootman et al. published a CBA paper evaluating the value of pharmacy services • Most early studies were conducted to justify the value of providing clinical pharmacy services (e.g., pharmacokinetic dosing) in the hospital setting National Center for Health Services Research and Development. Report of the Task Force on the pharmacist’s clinical role. J Am Pharm Assoc. 1971; 11(9):482-485 Bootman JL, Zaske DE, Wertheimer AI, Rowland C. Cost of individualizing aminoglycoside dosage regimens. Am J Hosp Pharm. 1979 Mar;36(3):368-70 57 History of Pharmacy Services (2) • 1990: Hepler and Strand proposed the concept that pharmacists should provide pharmaceutical care • Pharmaceutical care means “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” not inst cost care about analise we love • Research on pharmaceutical care services was extended to outpatient and community pharmacy settings Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990 Mar;47(3):533-43 58 History of Pharmacy Services (3) • The American College of Clinical Pharmacy (ACCP) Task Force on Economic Evaluation of Clinical Pharmacy Services published the following five papers = aplications for spriode of that • Schumock et al., Economic Evaluations of Clinical Pharmacy Services: 1988-1995 • Schumock et al.,Evidence of the Economic Benefit of Clinical Pharmacy Services: 1996-2000 • Perez et al., Economic Evaluations of Clinical Pharmacy Services: 2001-2005 • Touchette et al., Economic Evaluations of Clinical Pharmacy Services: 2006-2010 • Talon et al., Economic Evaluations of Clinical Pharmacy Services in the Unite States: 2011-2017 59 History of Pharmacy Services (4) • 2006: MTM services was mandated for high-risk patients as part of the Medicare Part D outpatient prescription drug benefit, which took effect in January 2006 • This stemmed from the Federal government’s recognition of the importance of MTM services provided by pharmacists 60 Medication Therapy Management • A type of service that optimizes individual patient therapeutic outcomes by managing drug therapy • Goal: to identify, prevent, and resolve medicationrelated problems (MRPs) • The Centers for Medicare and Medicaid Services (CMS) require Medicare Part D plan sponsors to establish an MTM program for patients who: A • Take at least 2-8 prescriptions D • Have at least 2-3 chronic conditions • Will likely incur a minimum medication cost ($1,623 in 2025) • MTM is considered an administration cost, because it is a components of the insurance plan’s bid 61 Types of Medication Reviews within MTM Comprehensive medication review (CMR) Targeted medication review (TMR) A systematic process to • collect patient-specific information • assess medication therapies to identify MRPs • develop a prioritized list of MRPs • create a plan to resolve them • The process to resolve a specific medicationrelated problems (MRPs) all ane Just medication netizations List i under 62 1 MTM Settings : Commute 2 Link 3 Phone Mia Jaet mem mem • Percentage of MTM encounters conducted by1: • • • • Community pharmacists: 22% Plan pharmacists: 30% Vendor in-house pharmacists: 35% Other health professionals: 23% • Community pharmacists provided CMRs in a timelier manner • Patient preferences2: live 1. Respondents were willing to spend about $30 to trade telephone MTM for clinic-based MTM so more sin him more the 2. They were willing to pay $13 more for MTM services at a Manl Min community pharmacy compared with clinic-based MTM Communit 1Adeoye wil OA, Farley JF, Coe AB, et al. Medication Therapy Management Delivery by Community Pharmacists: Insights from a National Sample of Medicare Part D Beneficiaries. J Am Coll Clin Pharm. 2019;2(4):373-382. doi:10.1002/jac5.1160 2Hong SH, Liu J, Wang J, Brown L, White-Means S. Conjoint analysis of patient preferences on Medicare medication therapy 63 management. J Am Pharm Assoc (2003). 2011;51(3):378-387. doi:10.1331/JAPhA.2011.10039 Value of Pharmacy Services 64 WTP for Pharmacy Services • Painter et al. reviewed 31 studies that assessed WTP for pharmacy services from 1999 to 2017 • Four studies from the US were conducted after Medicare Part D took effect • WTP for pharmacy services were estimated to be $13.31, $17.57, $21.37, and $33 • Factors contributing to this variation include: • Different ways the questions were presented • Inherent biases of WTP methods (e.g., starting point bias) • Respondent characteristics (e.g., income, number of medication respondent used) Painter JT, Gressler L, Kathe N, Slabaugh SL, Blumenschein K. Consumer willingness to pay for pharmacy services: An updated review of the literature. Res Social Adm Pharm. 2018;14(12):1091-1105. doi:10.1016/j.sapharm.2018.01.010 65 Outcomes of Pharmacy Services • An evaluation of 31 systematic reviews on pharmacist-led medication reviews found that: A • Significant reductions in medication and/or health care costs were reported in 35% of research studies • Results from the 12 meta-analyses suggested positive impacts on numerous health outcomes • No studies reported a reduction in mortality Pharmacy services for resuction M Mortality Jokanovic N, Tan EC, Sudhakaran S, et al. Pharmacist-led medication review in community settings: An overview of systematic reviews. Res Social Adm Pharm. 2017;13(4):661-685. doi:10.1016/j.sapharm.2016.08.005 66 Economic Evaluations of Pharmacy Services • Talon et al. conducted a systematic literature review of studies evaluating clinical pharmacy services (CPS) published in the US between 2011-2017 • Methods: • Search databases: PubMed, Ovid, and Embase • 19,555 potentially relevant papers from 2011-2017 als they • 115 studies were included in the final review of rese Talon B, Perez A, Yan C, et al. Economic evaluations of clinical pharmacy services in the United States: 20112017. J Am Coll Clin Pharm. 2019; 3: 793–806. https://doi.org/10.1002/jac5.1199 67 At Economic Evaluations of Pharmacy Services: Findings • Types of clinical pharmacy services: SA • General pharmacotherapy: managing several disease Mistau states and medications (41%) lot of mentions gener generen • Disease management : managing a single disease n or diseases e state or diseases (30%) S leybe asseasy just • Targeted drug programs: therapeutic management of a single drug or drugs (17%) &my program mestrations a • Top 3 clinical pharmacy service settings: • Hospital (34%) Is• Ambulatory care (28%) ↳ut • Community pharmacy (17%) a 68 Econ. Evaluations of Pharmacy Services: Findings (Cont.) A • Economic evaluation type • Descriptive studies that measured cost and/or outcomes of a CPS (55%) No Comparate • Comparative studies that measured cost or outcomes of a CPS and a comparator (37%) alternative or compared • Full economic evaluations that measured cost and outcomes of a CPS and a comparator (8%) everything A • Out of the 9 full evaluation studies: 87 • 4 studies reported the CPS as being more effective at a lower cost • 7 studies took the payer perspective, 1 took the provider perspective, and 1 took the societal perspective A most took Payer 69 Issues to Consider • Need to explain in detail what pharmacy services are being evaluated and how these services are provided these relails could influence the outcome • Need to consider how health consequences or benefits should be valued based on the type of pharmacoeconomic study conducted • All cost should be considered such as estimated salary per hour, cost of fringe benefits, cost of new equipment, programming or space - all costs Should re moved 70 Issues to Consider (Cont.) AAA always I need comparison graps • Consider including comparison groups; this could increase the confidence in study findings • Be aware of the silo mentality (only consider one budge) only considering Pharmais butget - Pharmacy budget • Pharmacy personnel time • Medication costs Other health care costs • ED visits • Hospitalization 71 Summary • Research on clinical pharmacy services has appeared in literature since the 1970s • More recent studies have measured the effect of MTM • Various terms were used to designate pharmacy-related services • Various methods (e.g., WTP) have been used to determine the economic values of pharmacy services • Issues related to pharmacy service research include: Wide variation in services Type of study conducted (e.g., CBA, CEA) Need to measure overhead and opportunity costs Lack of a control group, so it is hard to determine the true effect of services • Drug budge silo mentality • • • • 72