Statement of contribution
T ABLE 22 R ELEVANT RESOURCES IN THE VALMER STUDY
COST OF PROVIDING THE HMR HEALTH RESOURCE UTILISATION
Reimbursement to community pharmacy/ pharmacist Drug costs Hospitalisations
Reimbursement to GP GP visits Laboratory tests
Specialist visits
Having identified the relevant resources, the next consideration was the technique used to measure their consumption.
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 922.4.2.2 Estimation of resource consumption
2.4.2.2.1 Cost of providing the HMR
As discussed in Section 1.2.2.4, the funding model for HMRs involves reimbursement by Medicare Australia for both the community pharmacy and GP. There is no separate patient co-payment.xi For the purposes of this study, it was assumed that both the pharmacy and GP would claim for each HMR (that is, they would not forget or choose to not claim for their involvement). It was considered that this was the most conservative assumption regarding this cost, and the most risk averse from the government’s perspective, as per the economic protocol.
The amount received by a GP for their involvement in a HMR is fixed. In contrast, rural pharmacies may be eligible for an additional travel allowance between $10 and $60 per HMR if the pharmacist must travel greater than 10km from the pharmacy to the patient’s residence. Information was requested from Medicare Australia to account for this loading; however it was not provided. It was therefore assumed that no rural loading was applied to any HMR in the baseline scenario. This assumption was investigated in the scenario analyses, described in section 2.4.4 of this chapter.
In consideration of the cessation of the HMR facilitator program in the Fifth Community Pharmacy Agreement in 2010,18 no costs associated with promoting the program were considered.
2.4.2.2.2 Health resource utilisation
2.4.2.2.2.1 Measurement considerations
Two methods of resource measurement were considered to estimate health resource utilisation, namely direct measurement and modelling using expert opinion. Direct measurement would have ideally involved the study being of a randomised controlled design, similar to that undertaken by Sorensen et al.66 However, this was not
xi A patient cost may only be incurred if their GP does not bulk-bill during the follow-up consultation
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 93 considered feasible in consideration of the required sample size, as previously discussed.The second method considered for estimating resource usage was the use of expert opinion, as used by both Gilbert et al. and Krass et al. in their QUM Evaluation Projects.126, 139 Both studies used methods based on work by Rupp and Buurma whereby panels of experts were used to value interventions undertaken in community pharmacies.193, 198, 199 These studies involved counterfactual impact evaluation, whereby the experts were asked to predict what would have happened to the patient had the intervention not occurred, in terms of health resource consumption such as hospitalisation or GP involvement. This type of evaluation was used in preference to a controlled design due to ethical issues in denying patients standard practice for the purposes of evaluating it.
Recently, Tenni identified several deficiencies in the Rupp and Buurma methods (and consequently the studies by Gilbert et al. and Krass et al.) that limited the robustness of results obtained using them.204 These included their methods not accounting for:
1. potential detrimental effects of the intervention (that is, adverse effects may result from an intervention, as well as beneficial effects);
2. multiple potential consequences resulting from the same intervention (as opposed to a single “most likely” or “most valuable” consequence); and
3. another party undertaking the same intervention (most patients see multiple healthcare providers therefore there are many opportunities for the same intervention to be undertaken).204
To overcome these issues, Tenni (as described by Stafford et al., Appendix IX)191 developed a technique whereby experts assigned probabilities to several potential outcomes before and after an intervention.204 Moreover, the experts also indicated the likelihood of another party undertaking the same intervention to ameliorate the third issue described above.
It must be acknowledged that economic analyses performed using expert panels provide a lower level of evidence compared with studies where empirical data is collected, such as in randomised- or case- controlled studies.205 However, it has been
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 94 argued that expert opinion may be useful in areas where there is uncertainty, controversy or incomplete evidence,205 and the results of studies that have used expert panels should not be summarily dismissed.206 Given that the methodology developed by Tenni sought to improve the robustness of expert panel results, it was considered that this methodology was the most appropriate to estimate resource consumption for this study.An overview of Tenni’s methodology is presented in the following section.
2.4.2.2.2.2 Methodology overview Methodological framework
A conceptual model of Tenni’s methodology is shown in Figure 6. The model considers that three potential scenarios may occur when a DRP is present:
1. the DRP is not identified by the pharmacist nor anyone else involved in managing the patient;
2. the DRP is not identified by a pharmacist but is identified and addressed by another person involved in managing the patient’s health; or
3. the DRP is identified and addressed by a pharmacist.
In all scenarios, numerous health consequences (both beneficial and detrimental) may potentially result from either the DRP or its resolution. However, for the purposes of evaluating the pharmacist’s involvement in the patient’s management, only the effects resulting from Scenario 3 can be attributed to the pharmacist. The consequences of Scenarios 1 and 2 would occur regardless of whether the pharmacist was involved in the patient’s care and therefore become the counterfactual.
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 95FIGURE 6-CONCEPTUAL MODEL FOR ESTIMATING THE IMPACT OF PHARMACISTS' CLINICAL INTERVENTIONS ON HEALTH SERVICE UTILISATION AND QUALITY OF LIFE.“CI”