Post on 13-Mar-2020
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Clinicamp V
Session 14
CLINICAMP V – 29/04/2016
Comment valoriser la pharmaco-économie de la pharmacie clinique
Farmaco-economie met betrekking tot klinische farmacie: wat en hoe berekenen.
Who are we ?
Phn Charlotte Declaye Hôpitaux Robert Schuman, Luxemburg
• Clinical pharmacist (Clinical Pharmacy Certificate, UCL, 2014 – 2015, CHU UCL Namur)
• My clinical pharmacy activities: transversal activity in anticoagulation, project management for developping clinical pharmacy activities in surgery.
• Clinical pharmacy activities in HRS: dialysis, intensive care and transversal activities.
Phn Olivier Tassin Grand Hôpital de Charleroi • Clinical pharmacist in charge of St Joseph site at GHdC.
• My clinical pharmacy activities: antibimicrobial stewardship, team and projet management, informatic parametrisation for the prescribing tool.
• Clinical pharmacy activities in GHdC : surgery, geriatrics, intensive care and transversal activities.
IntroductionWhich clinical pharmacy activities have we/you developped with pharmaco-
economics evaluation ?• How can we / do we select the activities /campain to start ?• Which possibilities ?
• With whom ?Doctors and Nurses - WardsTechniciansOther health care worker
• How do we do it ? How can we evaluate ?
Back office Front office
Prescription validation ?Informatic tools to improve prescription
In a ward: How do we choose ?
Or transversal:Campain (e.g.: iv-p.os, guidelines adequacy,…)On a single therapeutic familly (e.g.: antibiotics, anti-coagulation,…)
Interactive method
What about your hospitals ? What about ours ?
• Realised
• Method (How ? With ? Tools ? Frequency ? How long, Feedback ? …)
• Future (What ? How to implement and assess these activities ? )
Tools for activities / campain
• Guidelines / knowledge
• Information access
• Interlocutor
• Standardized document for the follow-up
• Standardized codified activity
• Evaluation of the activity
Data availability/How to get the data?
Adapted from Van Bellinghen et al., An Introduction to Health Economics, Namur-Luxembourg, 2015
Internal hospital data (eg: medications consumption, monocentric disease
costs,…)
Epidemiology study� risk of outcome
Clinical study/meta-analysis� Efficacy data
Literature� QALYs
Databases (INAMI, KCE, CNS,…)� costs
Costing study� costs
When the methodology is defined and the needed data are known:
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Some examples:
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• IV – PO switch
• Parenteral nutrition
• Antibiotics
• Economic evaluation of pharmaceutical intervention in anticoagulation
Some examples:
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• Identification of over-consumed medication:
- LMWH => guidelines & control- IV Nutrition => new guideline + prescription & control in specific wards - Anesthetics => better tarification in the operating room- Sympathomimetic and associations => formulary revision and U.D. consumption. - Antibiotics: weekly antibiotic check
antibioprophylaxis => guideline update & control information about consumption in specific wards
- IV-oral switch in general => medication selection & control
CLINICAMP III – 13/06/2014
IV – PO switch
Quelques exemples 10
Antibiotics
Quelques exemples… 11
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CLINICAMP III – 13/06/2014
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• Tot intervention on antibiotic activity for 2015 = 909
• Total benefit for 2015: 4165 €/24h
• Global benefit: 4,60€/intervention/24h
• 359 intervention with no direct economic impact
• 105 interventions cost: 13,30€/intervention/24h
• 398 interventions make a benefit: 13,94€/intervention/24h
Methodology ? Périod = 24h, only the delta of medicati on cost, the benefits don’t include length of stay reduction, complication, re-hospitalisation, adverse drug eventprevention…
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• We are developping the codification of clinical pharmacy interventions in the patient file (link with clinical pharmacy advice):• More visibility
• Exhaustive statistics.
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CLINICAMP III – 13/06/2014
Parenteral nutrition
CLINICAMP III – 13/06/2014 CLINICAMP III – 13/06/2014
Economic evaluation of pharmaceutical intervention in anticoagulation
� Context in CHU UCL Namur :
� Clinical pharmacy activity in the follow-up of hospitalized patients taking a DOAC.
� Prospective study (Larock et al., 2014) on the appropriateness of ACOD prescription (based on « MAI » tool) show 49% of inappropriate prescription.
Study purpose:
To determine the net cost benefit of pharmaceutical intervention onDOAC prescription.
Economic evaluation of pharmaceutical intervention in anticoagulation
Method:
• Population settings:
• Decision tree model to evaluate the impact of pharmacist intervention on the risk of ADE secondary to inappropriate DOAC prescription
Inclusion Exclusion
Patients taking a DOAC for NVAF with a pharmaceutical intervention to optimizeprescription of the DOAC
Surgical patientsPatients admitted with a DOAC relatedadverse event (ADE)
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Economic evaluation of pharmaceutical intervention in anticoagulation
Method:
• Measurement and valuation of risks and costs:
• Univariate sensibility analysis: demonstrate the robustness of the analysisby taking different scenarios against pharmaceutical interventions.
Necessary parameters Tools to obtain
Theoretical risks of ADE Published in littérature
Individual probability of risk withoutpharmaceutical intervention
Published methodology
Pathology costs Hospital costs determined by DRGAmbulatory costs described in littérature
DOAC annualized costs and pharmacistcosts
Official Belgian data
Economic evaluation of pharmaceutical intervention in anticoagulation
91 patients
75 patients
36 patients withinappropriate
DOAC prescription
Results:
16 surgicalpatients excluded
52% appropriateDOAC prescription
Results:
Economic evaluation of pharmaceutical intervention in anticoagulation
Decision Tree model (DPL 8 Trial, 2014, Syncopation Software Inc)Prescription appropriée
0
Pas de dommages attendus
0,01
Risque très faible
0,1
Risque faible
0,4
RIsque modéré
0,6
Risque haut
52,8%
Surdosage
0
Pas de dommages attendus
0,01
Risque très faible
0,1
Risque faible
0,4
RIsque modéré
0,6
Risque haut
47,2%
Sous-dosage
Probabilitésd'occurenceselon Nesbit
Prescription inappropriée
Risque
Patientsous ACOD
Results:
Economic evaluation of pharmaceutical intervention in anticoagulation
2,13%
Saignement majeur
0,33%
Saignement intracrânien
0,76%
Saignement gastro-intestinal
Evènementshémorragiques
1,19%
AVC
0,97%
AVC ischémique ou origine incertaine
0,04%
Embolie pulmonaire
Evènementsthromboemboliques
Economic evaluation of pharmaceutical intervention in anticoagulation
Results:
Declaye et al., AFPHB, 2016
Results: Univariate sensitivity analysis
Economic evaluation of pharmaceutical intervention in anticoagulation
Paramètre variant Coûts évités Coûts à payer Balance*
Taux de prescription inappropriée = 28% 4 597€ 4 323€ - 274€
Taux de prescription inappropriée = 25% 3 063€ 4 323€ 461€
Paramètre variant Coûts évités Coûts à payer Balance*Diminution de probabilité d’occurrence à0,1 pour tous les patients
4 391€ 4 323€ - 68€
Coûts des traitements↓30% 7 954€ 4 070€ - 3 884€
Paramètre variant Coûts évités Coûts à payer Balance*
Coûts minimaux de chaque pathologie 363,4€ 4 323€ 3 959€
Coûts médians de chaque pathologie↓20% 6 363€ 4 323€ - 2 040€
Coûts médians de chaque pathologie↓ 45% 4 373€ 4 323€ - 50€
Coûts médians de chaque pathologie↑20% 8 440€ 4 323€ - 4 117€
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Conclusion – Take home messages
• Large range of possibilities to make economic evaluation in a hospital
• Different types of cost analysis are possible in a hospital (but time consuming)
• Cost analysis is a part of rational criteria for use of medication
• Compulsory structured methodology to reproduce the analysisover time and compare results
• Relevant data selection
• Collaboration between different healthcare actors needed
Let’s think about….
You want to develop the activity of therapeutic education for ambulatory delivery of hospital use therapy (e.g.: VIH, hepatite,…). Known qualitative impact but economically speaking
Which methodology/analysis can you imagine to prove the economic benefit for the hospital and to hire a new pharmacist?
Which data/tools do you need?
Back Up Slides: Types of economical
analysis
Cost-minimisation Cost-effectiveness Cost-benefit Cost-utility
Only costs are compared
Costs per life year Cost per eventavoided
Costs/QALY
The choice depends on the targeted audience, medicaltechnology, clinical outcome involved.
Adapted from Van Bellinghen et al., An Introduction to Health Economics, Namur-Luxembourg, 2015
Back Up Slides: Types of model
Decision Tree:Simple disease with
distinct event, limited time frame and no time
depedency
Markov Model:Characterizes a disease by
means of mutuallyexclusive health states
Discrete Event Simulation:
Timing and chronology of event is important
Adapted from Van Bellinghen et al., An Introduction to Health Economics, Namur-Luxembourg, 2015
Back Up Slides: PostulatsPostulats sont inhérents à chaque analyse économiqu e :
� Coûts hospitaliers ne proviennent que d’une seule institution hospitalière.
� Coûts ambulatoires sont considérés uniquement en cas d’AVC, car nous avons estimé que les coûts et les risques étaient identiques après 1 an dans les autres pathologies.
� Coûts indirects de l’AVC (ex: absentéisme professionnel) non pris en compte car pas de décès dans la population observée et population âge > à celui de la retraite.
� Risque de décès naturel semblable pour les 2 populations � pas de modélisation de son coût.
Back Up Slides: Annualization
� Taux d’actualisation = 3% (conforme aux guidances).
� Types de coûts concernés :
� Coûts ambulatoire directs médicaux de l’AVC � Coûts médicamenteux (anticoagulation à long terme dans la FA)
� Espérance de vie en 2015 considérée en fonction de l’âge moyen de la population incluse � annualisation sur 11 ans
But : Estimer un coût futur à l’heure actuelle
Cleemput, 2008; Cleemput, 2012