Hale Andrew, Merlo Greg, Nissen Lisa, Coombes Ian, Graves Nicholas
School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Royal Brisbane and Women's Hospital, Cnr Butterfield St and Bowen Bridge Road, Herston, Brisbane, 4029, Australia.
Australian Centre for Health Services Innovation, School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, 4059, Australia.
BMC Health Serv Res. 2018 Oct 1;18(1):749. doi: 10.1186/s12913-018-3557-0.
Current evidence to support cost effectiveness of doctor- pharmacist collaborative prescribing is limited. Our aim was to evaluate inpatient prescribing of venous thromboembolism (VTE) prophylaxis by a pharmacist in an elective surgery pre-admission clinic against usual care, to measure any benefits in cost to the healthcare system and quality adjusted life years (QALYs) of patients.
A decision tree model was developed to assess cost effectiveness of pharmacist prescribing compared with usual care for VTE prophylaxis in high risk surgical patients. Data from the literature was used to inform decision-tree probabilities, utility, and cost outcomes. In the intervention arm, a pharmacist prescribed patient's regular medications, documented a VTE risk assessment and prescribed VTE prophylaxis. In the usual care arm, resident medical officers were responsible for prescribing regular medications, and for risk assessment and prescribing of VTE prophylaxis. The base scenario assessed the cost effectiveness of a pre-existing pre-admission clinic pharmacy service that takes on a collaborative prescribing role. The alternative scenario assessed the benefits of introducing a pre-admission clinic pharmacy service where previously there had not been one. Probabilistic sensitivity analysis was conducted to explore uncertainty in the model.
In both the base-case scenario and the alternative scenario pharmacist prescribing resulted in an increase in the proportion of patients adequately treated and a decrease in the incidence of VTE resulting in cost savings and improvement in quality of life. The cost savings were $31 (95% CI: -$97, $160) per patient in the base scenario and $12 (95% CI: -$131, $155) per patient in the alternative scenario. In both scenarios the pharmacist-doctor prescribing resulted in an increase in QALYs of 0.02 (95% CI: -0.01, 0.005) per patient. The probability of being cost effective at a willingness to pay off $40,000 was 95% in the base scenario and 94% in the alternative scenario.
Delegation of the prescribing of VTE prophylaxis for high risk surgical patients to a pharmacist prescriber in PAC, as part of a designated scope of practice, would result in fewer cases of VTE and associated lower costs to the healthcare system and increased QALYs gained by patients.
Pre admission clinic study registered with ANZCTR-ACTR Number ACTRN12609000426280 .
目前支持医生 - 药剂师联合处方成本效益的证据有限。我们的目的是评估药剂师在择期手术入院前诊所对静脉血栓栓塞（VTE）预防的住院处方与常规护理相比的情况，以衡量对医疗系统成本的任何益处以及患者的质量调整生命年（QALYs）。
开发了一个决策树模型，以评估药剂师处方与常规护理相比在高风险手术患者VTE预防方面的成本效益。来自文献的数据用于确定决策树的概率、效用和成本结果。在干预组中，药剂师开出患者的常规药物，记录VTE风险评估并开出VTE预防药物。在常规护理组中，住院医生负责开出常规药物以及进行VTE预防的风险评估和开药。基础方案评估了承担联合处方角色的现有入院前诊所药房服务的成本效益。替代方案评估了引入以前没有入院前诊所药房服务的益处。进行了概率敏感性分析以探索模型中的不确定性。
在基础方案和替代方案中，药剂师处方均导致充分治疗患者的比例增加，VTE发生率降低，从而节省成本并改善生活质量。基础方案中每位患者节省成本31美元（95%CI： - 97美元，160美元），替代方案中每位患者节省成本12美元（95%CI： - 131美元，155美元）。在两种方案中，药剂师 - 医生联合处方均使每位患者的QALYs增加0.02（95%CI： - 0.01，0.005）。在支付意愿为40,000美元时具有成本效益的概率，基础方案为95%，替代方案为94%。
作为指定执业范围的一部分，将高风险手术患者VTE预防的处方委托给入院前诊所（PAC）的药剂师开方者，将导致VTE病例减少，医疗系统成本降低，患者获得的QALYs增加。
入院前诊所研究已在澳大利亚和新西兰临床试验注册中心（ANZCTR）注册，注册号为ACTRN12609000426280 。
