Healthcare has become a complex multidisciplinary science where we find, on the one hand, disease-related actions, such as diagnosis, treatment, prevention, nursing and chart review, while on the other hand, management skills are needed to keep health and economics in balance. The current financial and economic crisis has had a worldwide impact that also obliges hospital administrators to review, if not cut, expenditure and to work even more efficiently. Within this context, clinical pharmacy services are developing because pharmacists believe them to be excellent tools to guarantee a safe, rational, effective and cost-effective health technology, resulting in a better outcome for the patient and a health economic benefit for hospital administrators.
During the past few decades, many economic evaluations of clinical pharmacy services have been published in the literature and have been thoroughly assessed and commented on in multiple reviews Citation[1–5]. Unfortunately, most individual economic evaluations suffer from a poor design and, therefore, lack the necessary quality to justify (dis)investment in clinical pharmacy services. As this has led to a series of comments regarding the reproducibility and generalizability of cost–effectiveness results, multiple authors have called for a standard for health economic research in this domain and have even written recommendations to investigators, authors and editors. The most important issues include the implementation of a control group, provision of sufficient details on the clinical pharmacy service and the setting in which it is delivered, inclusion of all working costs when calculating the net benefit, a correct valuation of non-monetary outcomes, discussion on possible bias and the uncertainty of data, and the conduct of an incremental analysis. Despite these issues, existing research indicates that clinical pharmacy services tend to have favorable benefit-to-cost ratios (even when neglecting the excessive amounts reported on cost avoidance), depending on the type of service and the setting.
Some literature reviews have adopted a ‘league-table’ approach, ranking clinical pharmacy services according to their benefit-to-cost ratio Citation[5]. Such a ratio shows how much monetary benefit is generated by a specific service for each dollar invested. A comparison of benefit-to-cost ratios may aid hospital administrators and pharmacists to decide which clinical pharmacy service to implement. The league-table approach is attractive because it combines the criteria of cost–effectiveness and affordability in decision making. However, the development of a league table requires comprehensive data on the costs and effects of the full range of clinical pharmacy services. Such data are not usually available and may not be transferable to the local decision-making context facing the hospital administrator and pharmacist. Rather than relying on a league table, a replacement approach can be used. This approach is based on the identification of an alternative health technology that, if cancelled, would provide the money needed to implement the clinical pharmacy service. If the effects of the clinical pharmacy service exceed the effects of the other technology, the replacement of the health technology with the clinical pharmacy service would contribute to a more efficient allocation of resources.
It should be noted that the use of replacement and league-table approaches to inform hospitals about clinical pharmacy services is likely to be inhibited by the restrictive decision-making context facing hospital administrators. Decision-makers do not get to choose a selection of cost-effective interventions out of a list of all possible health technologies (including clinical pharmacy services) that can be provided in a hospital setting. Instead, a hospital may already be funding an array of health technologies that may or may not be cost effective but are well-accepted for psychological, political or other reasons. This may reduce the ability of hospital administrators to dispose of existing health technologies and replace them with more cost-effective clinical pharmacy services.
Next to cost–effectiveness, we can look at other indicators for the need of clinical pharmacy services. One of these could be the willingness to pay for having a clinical pharmacist working with the physicians, hospital administrators and even the government. Often, when medical staff have the opportunity to temporarily work with a clinical pharmacist in their team, the continuation of this service is requested and budgets are freed up to pay for the pharmacist’s wage. In some European countries, the government finances clinical pharmacy projects to implement these services with a view to, in the end, save on the national budget. Common clinical pharmacy services relate to antibiotic therapy, adjusting therapy and posology to the patient, preventing adverse drug events, reviewing medication history, intravenous-to-oral switch, anticoagulation therapy, and discharge management.
Although the number of published economic evaluations of clinical pharmacy services increases over time, less attention has been paid to the use of such economic evaluations by local hospital administrators and pharmacists. A systematic review identified barriers to the use of economic evaluation in local decision making, including inflexibility of healthcare budgets, political objectives, effectiveness being of greater importance than cost–effectiveness, focus of physicians on an individual patient rather than on a population perspective, lack of time to make informed decisions, lack of timeliness of economic evaluation and methodological uncertainties surrounding the technique of economic evaluation itself Citation[6]. To address these challenges, a number of actions have been proposed, including the need for training hospital administrators and pharmacists in economic evaluation and health economics, increased practical relevance of studies, enhanced comparability of studies, more flexibility of healthcare budgets and easier access to studies Citation[7].
It is our belief that more international consensus surrounding methodological guidelines on how to conduct economic evaluations and on recommendations for reporting the results of such studies would aid the evaluation and adoption of clinical pharmacy services in hospitals. If economic evaluations adopt a high-quality design and findings are disseminated using a standardized reporting template, such data can be used by hospital pharmacists and hospital administrators to justify the implementation of a clinical pharmacy service resulting in a better outcome for the patient and health economic benefit to hospital administrators. Such studies may aid decisions by medical departments or hospital administrators to pay for clinical pharmacy services from the hospital or medical-department budget.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
References
- Willet MS, Bertch KE, Rich DS et al. Prospectus on the economic value of clinical pharmacy services: a position statement of the American College of Clinical Pharmacy. Pharmacotherapy9, 45–56 (1989).
- Schumock GT, Meek PD, Ploetz PA et al. Economic evaluations of clinical pharmacy services: 1988–1995. Pharmacotherapy16, 1188–1208 (1996).
- Kaboli PJ, Hoth AB, McClimon BJ et al. Clinical pharmacist and inpatient medical care. A systematic review. Arch. Intern. Med.166, 955–964 (2006).
- De Rijdt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am. J. Health Syst. Pharm.65(12), 1161–1172 (2008).
- Perez A, Doloresco F, Hoffman JM et al. Economic evaluations of clinical pharmacy services: 2001–2005. Pharmacotherapy28(11), 285e–323e (2008).
- Eddama O, Coast J. A systematic review of the use of economic evaluation in local decision-making. Health Pol.86, 129–141 (2008).
- Hoffmann C, Graf von der Schulenburg JM; on behalf of the EUROMET Group. The influence of economic evaluation studies on decision making: a European survey. Health Pol.52, 179–192 (2000).