A central feature of any high performing healthcare system or organisation includes best practice in medicines use and management. As all aspects of healthcare are under varying degrees of financial stress these days, cost controls and appropriate use of medicines must support the highest standards of clinical practice and safe patient care.
Medicines optimisation is one strategy as the use of medicines influences the quality of healthcare across the whole patient treatment pathway.
Failure to optimise the use of medicines across this pathway may arise from:
- misuse of medicines (failure to prescribe when appropriate, prescribing when not appropriate, prescribing the wrong medicine, failure to reconcile medicines use across clinical hand-offs;
- “clinical inertia” and failure to manage patients to goal (e.g. management of diabetes, and hypertension post aMI) [O’Connor PJ, SperlHillen JM, Johnson PE, Rush WA, Blitz WAR, Clinical inertia and outpatient medical errors, in Henriksen K, Battles JB, Marks ES et al, editors, Advances in Patient Safety: From Research to Implementation Vol 2: Concepts and Methodology), Agency for Healthcare Research and Quality, 2005];
- failure to use or follow best-practice and rational prescribing guidance;
- lack of synchronisation between the use of medicines (demand) and procurement (supply), with an impact on inventory management and
- loss of cost control of the medicines budget.
The essential challenge is ensuring that the healthcare system and its constituent parts are fit for purpose to address and avoid these failures or at least minimise their negative impact.
Medicines costs are the fastest growing area of expenditure and comprise a major constituent of patient treatment and recovery.
The cost of drug mortality was described in 1995 [Johnson JA, Bootman JL. Drug-related morbidity and mortality; a cost of illness model. Arch Int Med. 1995;155:1949/56] showing the cost of drug mortality and morbidity in the USA and costed the impact at $76.6 billion per year (greater than the cost of diabetes).
The study was repeated five years later [Ernst FR, Grizzle A, Drug-related morbidity and mortality: updating the cost of illness model, J Am Pharm Assoc. 2001;41(2)] and the costs had doubled.
Evidence from a variety of jurisdictions suggests that drugs within the total cost of illness can be substantial, for instance:
- Atrial fibrillation: drugs accounted for 20% of expenditure [Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda J-G, Van Gelder IC, The cost of illness of atrial fibrillation: a systematic review of the recent literature, EP Eurospace (2011)13 (10):1375-1385]
- Pulmonary arterial hypertension: drugs accounted for 15% in a US study [Kirson NY, et al, Pulmonary arterial hypertension (PAH): direct costs of illness in the US privately insured population, Chest, 2010; 138.]
Upward pressure on the medicines budget include:
- medicines with new indications (be careful, some of this is an artefact of drug regulation gamed by manufacturers)
- changes in clinical practice which has an uplift effect on medicines use (especially if guidelines are poorly designed)
- increasing the number of prescribers (keep in mind that prescribers are cost-drivers)
- medicines for previously untreated conditions (this trades-off with reduced costs in misdiagnosis, mis-/delayed treatment)
- therapeutic improvements over existing medicines, and
- price increases (think of monopoly generic manufacturers, for instance).
Downward pressures include:
- effective procurement methods (e.g. avoid giving winners of tenders ‘the whole market’ and ensure that rules enable generic competition)
- use of drug and therapeutic committees and drug review processes (it is all about knowing where the money goes for improving value)
- use of prescribing and substitution guidelines e.g. generic substitution (oh yes, enforcing it, too; it also helps to ensure OTC medicines are not reimbursed by insurance as this adds to competitive pricing pressure and improves patient choices)
- positive and negative hospital formularies (yes, hard choices)
- pro-active clinical pharmacy services engaged in both business and professional domains, (this means ensuring the expertise of pharmacists are central to decision-making) and
- reduction of waste (you don’t want to know how much drug waste there is but estimates are up to 30% of expenditure is waste).
Additional sources of pressure in either direction come from:
- population case-mix (that means paying attention of the health of the nation)
- changing prevalence and incidence over time (also paying attention to the determinants of ill-health, particularly avoidable causes and effects by age cohorts)
- performance and efficiency of clinical workflow across the patient pathway (this is where money gets wasted at light speed and where it can also be saved; clinicians are in control of workflow so engaging them in areas where they can make a difference matters a lot)
- medicines payment and reimbursement practices including patient co-payments where they exist and the structure of hospital budgets or financing, (do we want to discuss the unintended and perverse consequences of the payment system?) and
- healthcare system regulations (yes, where many problems are caused in the first place).
Many of the drivers of problems can be addressed through a combination of professional staff development, better use of information, particularly within decision-support systems to support guidelines and prescribing compliance, and organisational interventions.