Focus on Evidence-Based Medicine and Drug Policy Development

The pharmacist's ability to apply medication information skills to drug policy decisions will be of growing importance in this changing health care environment. This can be done by identifying trends of inappropriate medication use in a group of patients and providing supporting scientific evidence to help change behavior. Continued growth in national health expenditures has raised the concern of government, insurance agencies, health care providers, and the public in identifying strategies to control spending while maintaining access to quality health care. With $216 billion spent on pharmaceuticals in 2003 (increased from $194 billion in 2002), inevitably, questions arise about the value of services received. These increases in pharmaceutical costs are of particular concern especially in light of the recent approval of the Medicare drug benefit. The Medicare Prescription Drug Improvement and Modernization Act has several provisions that will affect pharmacy practice including one that requires participating in health plans to create medication therapy management programs to ensure that the covered medications are used appropriately by high-risk patients. Likewise, the IOM recently completed a 3-year study of the uninsured with a recommendation that universal health insurance coverage be available in the United States by 2010. In 2001, uninsured Americans received $35 billion in uncompensated medical care; $30 billion was ultimately paid for with tax dollars. Although a list of insurance benefits has not been defined, they will be created based on evidence of improved patient care.

In recent years, there has been a shift from a fee-for-service, inpatient focus, to a capitated, managed care, ambulatory focus. Managed care—a process seeking to manage the delivery of high-quality health care in order to improve cost effectiveness—is consuming an ever-increasing portion of health care delivery. Today, providers are relying less on impressions of what may be happening in a practice setting and more on data that are actually being collected in that same group of patients (e.g., number of patients receiving appropriate dose of drugs). Goals are set for a particular group of patients (e.g., all patients receive beta-blocker therapy after a myocardial infarction) based on evidence found in the scientific literature. This connection of applying the scientific information to the patient care setting is made through evidence-based medicine. Evidence-based medicine is an approach to practice and teaching that integrates current clinical research evidence with pathophysiologic rationale, professional expertise, and patient preferences to make decisions for a population. This has strengthened the need for pharmacists to have a solid understanding of medication information concepts and skills. Pharmacists need to be able to evaluate the medication use issues for a group of patients; search, retrieve, and critically evaluate the scientific literature; and apply the information to the targeted group of patients. Evidence-based medicine techniques are used in health care organizations in the development and implementation of a variety of quality assurance tools (e.g., therapeutic guidelines, clinical pathways, MUEs, and disease state management) in an effort to improve patient outcomes and decrease costs. All of these situations require pharmacists to use medication information skills and to have various kinds of medication information support at the practice site or easily accessible at a remote site. The process of evidence-based medicine requires that systems be developed to measure and report processes and outcomes that can be used to drive quality improvement efforts. Data can be collected and analyzed by a medication information specialist using scientific methods to support the decision-making process in a managed care organization. Outcomes research can be used to identify the effectiveness of pharmaceutical products and services in achieving desired health outcomes. Likewise, the branch of outcomes research, pharmacoeconomics, provides tools to assess cost, consequences, and efficiency. This will be discussed more fully in .