Pharmaceutical care measuring outcomes

Because changes in health outcomes result from so many different and simultaneous factors, measuring the relationship between health outcomes and any specihc determinant remains difficult. Spending on pharmaceuticals is often used as a proxy for the value of pharmaceutical care but often ignores noncompliance, overprescription, over-the-counter sales, and the very definition of a pharmaceutical product. Therefore, the results presented in this chapter should be examined with care, and their precision should not be overstated. 

Knoell DL, Pierson JF, Marsh CB, etal. 1998. Measurement of outcomes in adults receiving pharmaceutical care in a comprehensive asthma outpatient clinic. Pharmacotherapy 18 1365. 

Patient satisfaction and quality of life are the two most common methods of measuring the humanistic outcomes of care. Improvements in patients quality of life have not been consistently demonstrated however, there is evidence that many of these studies purporting to provide pharmaceutical care were in fact disease state management or specific drug-focused programs in which pharmacists did not assume responsibility for all of the patients drug therapy treatment goals. 

Identifying and measuring the outcomes of a pharmaceutical care adherence plan is also important. Objective measures of improved health status and/or reduced health care expenditures document success in a well-designed pharmaceutical care plan. Examples of measurable outcomes include a reduction in inappropriate use of the health care system (e.g., fewer emergency department visits for asthma exacerbations) or improved control of the patient s disease (e.g., HbAic levels below 1% in a patient with type 2 diabetes). 

In the time that has passed since the original ACCP prospectus, the literature has continued to grow in both depth and breadth of evidence supportive of the financial justification of clinical pharmacy services. New service models and philosophies of practice have developed in the past 6 years, the most notable being that of pharmaceutical care. " In addition, our ability to evaluate scientifically and measure the impact of clinical services on costs and outcomes has matured with the increased understanding and use of analytical techniques in health economics and pharmacoeconomics. " The effect of these advances on the quality and quantity of literature is unknown. The ACCP Board of Regents thus asked the ACCP Publications Committee to update this prospectus. 

Some of the more common performance measurement systems used to assess pharmaceutical outcomes include report cards, balanced scorecards, clinical value compasses, profiling, performance-based evaluation systems, and others. The goals of pharmaceutical performance measurement systems are to 1) compare treatment modalities fairly 2) recognize and promote good care 3) identify and eliminate substandard care and 4) improve the level of care overall.Because performance measures can include data over the course of treatment, the outcomes of alternative therapies and practices may be detected. The end goal of any performance measurement system should not be cost containment only improving patient outcomes must be a primary concern, keeping in mind the cost effectiveness of the therapy and sustainability of the system. 

David Eddy at Duke University has written extensively on the problems and potential solutions related to pharmaceutical performance measurement systems. According to a U.S. survey, the most commonly perceived problems with pharmaceutical performance measurement systems are limitations with billing and administrative databases, lack of time to review summary data by physicians, and incomplete data. Other limitations include risk adjustment (what if my practice has sicker patients), overreliance on administrative (claims) data rather than clinical data (therefore lacking key patient outcomes), patient individuality and variation in medical practice, and lack of capacity for taking into account a discipline-specific rather than a whole programs-oriented CQI approach. There has also been some debate on the reliability of performance measurement systems to assess the true impact of physician care on the quality of health care.t ... 

The consensus statements that were drafted identified several needs in pharmacy Create a mission statement, develop standards for pharmacists to apply in managing pharmaceutical care, demonstrate and communicate the value of pharmaceutical care to healthcare, measure the quality and outcomes of services, strengthen political action, and convince the public and payers of the benefits of pharmaceutical care. The obstacles facing practice were also noted. The overarching conclusion was that pharmacy had to actively demonstrate and communicate its value to healthcare. 

When any form of policy - economic or otherwise - is intended to have an impact on pharmaceutical care, it is important to measure its intended (and possibly unintended) effects. The present chapter will consider methods that can be used to monitor those effects on both process and outcomes. Monitoring process involves a regular review of the activities that make up dmg management and delivery programs, and that are intended to achieve policy objectives as regards to both health and expenditure it is sometimes more clearly known as internal assessment. Monitoring the results, i.e. the outcomes, will show whether these policy objectives are being achieved this is sometimes termed external assessment. 

About the Author Dr. Bentley is an Associate Professor in the Department of Pharmacy Administration and Research Associate Professor in the Research Institute of Pharmaceutical Sciences at the University of Mississippi School of Pharmacy. He received a B.S. in pharmacy and an MBA from Drake University and an M.S. and Ph.D. in pharmacy administration from the University of Mississippi. In addition to statistics, Dr. Bentley s teaching interests focus on the organization, delivery, financing, and outcomes of health care. His research interests include understanding the role of pharmacy practice in how medications and the medication consumption experience affect quality of life, the use of quality-of-life measures as clinical tools, and empirical investigations of ethical issues in pharmacy and research. 

Pharmaceutical outcome data are also used to improve the quality of care, identify potential problems, and improve patient outcomes. These data are often used within a continuous quality improvement (CQI) cycle, where rate-based performance measures are tracked over time and used in conjunction with control charts to show changes in quality and assess the impact of programs or changes in process. Information can be fed back to front line health care practitioners, areas for possible improvement identified, appropriate changes made, and reassessments initiated. 

The United States has several major performance measurement systems in place. Two of the most important systems are those directed by the National Committee for Quality Assurance (NCQA) for managed care organization (MCO) accreditation and The Joint Commission on Accreditation in Healthcare Organizations (JCAHO) for health care organization accreditation. Both NCQA s performance measurement system, HEDIS, and JCAHO s IMSystem include several pharmaceutical outcomes indicators. 

All the criteria so far discussed are certainly important but it is also crucial that what is provided meets the patient s reasonable expectations with regard to quality in the broad sense [10]. The meaning of quality at one level may be to equate it to effectiveness, but the definition of quality certainly goes beyond a reflection of how patients perceive the effectiveness of the services they receive. The definition of quality is also likely to differ depending on cultural expectations and values, as well as the nature of the health care system through which pharmaceutical services are delivered. For example, a US patient may equate quality to freedom of choice, while a patient in the UK may equate it to shorter waiting times or to reduced variations in services across the system. Expert definitions of quality include the dimensions of access, appropriateness, and technical and/or interpersonal excellence as measured by the health outcomes achieved [3,10]. Therefore access to pharmaceutical services (i.e. availability of prescribers, pharmacies and medicines) should be appropriate to what patients need and delivered in a manner that displays good levels of professional practice. 

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