Clinicamp V session 14 Declaye Tassin - Belgium...9/05/2016 1 Clinicamp V Session 14 CLINICAMP V –29/04/2016 Comment valoriser la pharmaco-économie de la pharmacie clinique Farmaco-economie

9/05/2016

1

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:

9/05/2016

2

Some examples:

7

• IV – PO switch

• Parenteral nutrition

• Antibiotics

• Economic evaluation of pharmaceutical intervention in anticoagulation

Some examples:

8

• 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

9/05/2016

3


14

15 16

• 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…

17 18

9/05/2016

4

• We are developping the codification of clinical pharmacy interventions in the patient file (link with clinical pharmacy advice):• More visibility

• Exhaustive statistics.

19


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.


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)

9/05/2016

5


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


91 patients

75 patients

36 patients withinappropriate

DOAC prescription

Results:

16 surgicalpatients excluded

52% appropriateDOAC prescription

Results:


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:


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


Results:

Declaye et al., AFPHB, 2016

Results: Univariate sensitivity analysis


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€

9/05/2016

6

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.


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


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

Documents

Clinicamp V session 14 Declaye Tassin - Belgium...9/05/2016 1 Clinicamp V Session 14 CLINICAMP V –29/04/2016 Comment valoriser la pharmaco-économie de la pharmacie clinique Farmaco-economie