Tuesday, August 17, 2010

The role of pharmacists

An interesting piece in the New York Times points out the growing role for pharmacists as part of the health care system in the United States.  In addition to providing prescriptions, some pharmacists are now helping to monitor unsafe drug interactions more carefully, to monitor refills of prescriptions (as a proxy for whether the drugs are being taken), offering more counseling, teaching patients in individual and group sessions, and even offering classes that feature exercise.

Is this a good use of their time?  For the entire health care system it is probably a great deal as long as the activities of the physician and the pharmacist are coordinated.  In systems that are truly systems (where someone stands to benefit from the coordination) this should decrease costs as someone has the incentive to control the sum of the costs.  However, in unorganized systems it is not clear.

To study the incentives, we could simply determine whether there is a way to decrease costs while achieving the same objective (i.e. a cost minimization exercise focused on the patient's health) or we could do a cost-effectiveness analysis and ask whether giving the pharmacist more responsibility (and thinking about what training might be necessary to do so) results in higher or lower expenditures and better health.  Lower costs and better health--of course give them more responsibility.  Higher cost and better health--have to ask whether it is worthwhile.

As a side note, if extra training is required, someone has to bear the cost of extra training.  Note that the pharmacist and owner of at least one store have started a business to educate others.  This suggests that they see this as a profitable opportunity that should be adopted by others.  It will be interesting to follow the developments.

Monday, August 9, 2010

The Many Costs of Seeing a Doctor

An interesting article in the Baltimore Sun describes a new set of websites in England by which people can answer a questionnaire and receive a prescription without ever seeing the doctor.  This is not for patients with an established relationship to have a follow-up--this can be for people who literally have never met the physician before.

It is interesting to me that most of the medical professionals who are quoted in the article talk about this being useful for people who don't have access are who are in areas without easy access--or they don't like it at all.  While I am not a physician, I believe I would still tend to focus on at least trying to get to an urgent care center (if one of those is accessible) rather than using this type of service.  I tend to agree with whoever wrote the headline for the article--"if you don't have the time just click here" and would assume that many people who will use this service will be busy individuals who feel they don't have the time to both with going to see a physician in person if the issue can be taken care of over the internet.

When assessing something like this, we would simply have to hope that the questionnaire has enough points at which patients are directed to stop and go to see a physician that patients do not end up trading convenience against safety.   What risks to patient safety are we willing to experience to get faster care?  At the societal level?  At the individual level?  What if we have a serious shortage of physicians if payments to physicians really are cut as steeply as suggested under health care reform?  Hypothetically, the duration of the delay without access to this type of service could lead to a need for this type of service and it would really just be trading off one type of risk to safety (delayed care) with another type of risk to safety (care via the net).

Also, I would hate to think of the implications of any security failure if people are sending pictures of rashes, etc. over the web.  Yes, I once posted some pictures of my (then) 4 year old's foot which was infected, but I'm not sure what other body parts I would (or would not) be willing to send for fear of security issues.  That raises a whole different set of cost and benefit tradeoffs.

Tuesday, August 3, 2010

infant mortality rate in Baltimore

An article in the Baltimore Sun points out that the infant mortality rate among African Americans in Baltimore City in 2009 was 15.8.  If  we look to the CIA World Factbook table on estimated infant mortality rates in 2010, we find that this suggests that some of the population local to the school of public health at which I work has an infant mortality rate higher than Botswana and other middle and lower income countries.  The article in the Sun pointed out that the infant mortality rate in the county that surrounds Baltimore City is also relatively high, although not as high as in the City.

At least some of this seems to be due to placing infants in dangerous sleeping positions.  The article pointed out that 26 of the children who had died had been in dangerous sleeping postitions.  What would it be worth to save 26 children?  Since we don't know who these 26 will be in advance how much would we be willing to spend to counsel each child's parents and caregivers?  Should we count the lives saved?  Life years saved?  Quailty of life saved?

Regardless of what else could be done to reduce the infant mortality rate in the local African American population, counseling mothers, fathers, and other family members on proper sleeping positions is likely to be a highly cost-effective way of reducing this rate--at least as long as we can convince people to change the way that the children sleep.  Sometimes, despite the fact that people tend to know the facts about a problem, they are slow to change their behavior, even when it can affect a child's health.  The key is to figure out where the resources to try to bring changes in sleeping positions and other issues related to infant mortality will come from; what else individuals and the government may have to be put aside; and what else the parents, local health care providers, and local government need to do to improve infant health in the local population.