Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance

OBJECTIVE

To determine the economic impact of an interventional programme aimed to increase the rate of clinical interventions undertaken in community pharmacy. STUDY DESIGN AND PERSPECTIVE: A randomised controlled trial of 4 parallel groups of pharmacies, conducted from a government perspective. Economic evaluations were based on savings/costs attributable to healthcare costs avoided, healthcare costs incurred by the pharmacists' actions, change in medication costs, pharmacy time and telephone calls made by the pharmacist. The study was conducted during November and December 1996 and costings were based on 1997 figures.

INTERVENTIONS

A professional fee-for-service [10 Australian dollars ($A; $A1 = 6.50 US dollars) per intervention] and education (an intensive 1-week course or advanced education) were implemented in an attempt to increase clinical interventions by the pharmacists. Group A pharmacies (n = 10) served as a control group and received neither education nor remuneration; group B received education and professional remuneration (n = 9); group C had received prior continued education and now received advanced education and professional remuneration (n = 11); and group D received professional remuneration with no education.

MAIN OUTCOME MEASURES AND RESULTS

The proactive clinical interventions in group C saved a mean of $A85.35 per 1000 prescriptions [95% confidence interval (CI)-$A157.11 to $A24.95). This was 4 times greater than savings generated by pharmacies in group B (mean savings of $A25.65 per 1000 prescriptions) and 6 times greater than control pharmacies. A sensitivity analysis which extrapolated results to Australian prescription figures showed that the control group was capable of generating savings in the order of $A2.4 million per year while pharmacists in group C would save the healthcare system $A15 million per year.

CONCLUSIONS

These results provide the first economic estimates for the provision of clinical interventions in Australian community pharmacies. It is believed that they illustrate the value of pharmaceutical services to the healthcare system and to the Australian community in terms of both quality of care and savings.

Delivery of medication to psychiatric patients in community health services in New South Wales

OBJECTIVE

We investigated the supply and monitoring of medication to patients who attend community mental health services in NSW.

METHOD

The staff at four metropolitan and one rural community centre health service were interviewed. Information sought included policies and procedures concerning medication, the delivery of medication to patients, and staff reports concerning their knowledge and practice related to the legal requirements of the New South Wales Poisons Act 1966.

RESULTS

Sixty-five (62%) of 104 coordinators, medical officers and staff who were responsible for case managing patients were interviewed. The centres all differed in their existing policies and practices and the extent to which they were supported by their local hospital and retail pharmacies. Only one centre had a designated pharmacist and this was a part-time position.

CONCLUSIONS

The delivery of medication at most centres is a fairly ad hoc arrangement with staff organising medication as best as they can. At times the supply of medication to patients fails to comply with legal and New South Wales Department of Health requirements.

Multiple medication use in the elderly. Use of prescription and non-prescription drugs in an Australian community setting

OBJECTIVE

To document the extent of polypharmacy or multiple medication use in the elderly.

DESIGN

Cross-sectional examination of an age cohort of a community.

SETTING

Community-based study in Dubbo, NSW, in 1988-1989.

SUBJECTS

All non-institutionalised residents aged 60 years and over, numbering 1237 men and 1568 women.

MAIN OUTCOME MEASURES

Assessment of use of prescription and non-prescription drugs, recent hospitalisation, years of education, psychosocial variables.

RESULTS

18% of men and 25% of women were currently using three or more classes of prescription drugs. The corresponding values for two or more classes of non-prescription drugs were 29% and 44%. Of those who were using multiple prescription drugs 56% of men and 76% of women were also using multiple non-prescription drugs. In a multiple logistic model, the following possible predictors of multiple drug use were included: hospitalisation in the last six months, age, sex, depression, life satisfaction and education. Multiple prescription drug use was significantly predicted by recent hospitalisation (odds ratio [OR] = 2.40; 95% confidence interval [CI], 1.63-3.56), increasing age (e.g. 70-79 years versus 60-69 years; OR = 2.54; CI, 1.97-3.25), female sex (OR = 1.59; CI, 1.25-2.01) and increasing depression (e.g. highest tertile of depression scale versus lowest; OR = 2.52; CI, 1.84-3.42). Multiple non-prescription drug use was significantly predicted by female sex (OR = 2.38; CI, 1.95-2.92) and increasing depression (OR = 2.77; CI, 2.16-3.56). For prescription items, non-prescription items, and both categories in combination levels of use 20% above the population average have been documented.

CONCLUSIONS

Polypharmacy in the elderly population appears to be predicted by recent hospitalisation, increasing age, female sex and increasing depression. There is potential for drug-drug interaction to occur, but the findings suggest target areas for preventive action.

The clinical application of the interferons: a review. NSW Therapeutic Assessment Group

OBJECTIVES

To review the clinical information on the use of alpha, beta and gamma interferons and to classify the use of alpha interferons in Australia according to approved indications, indications for which there is good supporting evidence and indications where therapy is under investigation; and to estimate the cost of therapy with alpha interferons in New South Wales in 1991.

DATA SOURCES

Data were obtained from computerised literature searches.

DATA EXTRACTION

A position paper was drafted on behalf of the NSW Therapeutic Assessment Group (NSWTAG). This was circulated to clinicians identified as having a particular interest in the use of the interferons in major NSW teaching hospitals, for comment and amendment where necessary.

CONCLUSIONS

Two forms of alpha interferon, interferon alfa-2b and interferon alfa-2a have been approved for use in Australia, interferon alfa-2b for use in the management of hairy cell leukaemia and condylomata acuminata and interferon alfa-2a for use in the management of hairy cell leukaemia and human immunodeficiency virus (HIV) related Kaposi's sarcoma. Applications have been lodged for the use of interferon alfa-2b in HIV related Kaposi's sarcoma, cutaneous basal cell carcinoma and hepatitis B and C and for the use of interferon alfa-2a in the management of hepatitis B, cutaneous T-cell lymphoma and metastatic renal cancer. Interferon alfa-n1 is not available in Australia except for use in a clinical trial in patients who are HIV seropositive. The use of the alpha interferons is currently under investigation in a wide variety of other diseases, with the likelihood that other indications will soon be established. However, the alpha interferons are generally not regarded as first line agents. Beta and gamma interferons have been studied less intensively than the alpha interferons, but it is likely that selected applications for their use will also be defined with the passage of time.