Current services
The social and economic value of community pharmacies services is depicted in Table
1. The added value of community pharmacies services was the result of the difference between a scenario with and a scenario without the evaluated services. Table
1 also identifies the estimated population covered in total (which represents 40.3% of the Portuguese population), the total number of services and total pharmaceutical time spent to provide such services.
Table 1
Social and economic value of the current community pharmacies services
Population Covered (n) | 4,180,190 | 4,180,190 | 0 |
Estimated number of pharmaceutical services (n) | 120,675,438 | 0 | 120,675,438 |
Time spent in services (hours) | 11,087,135 | 0 | 11,087,135 |
Social Value |
Quality of Life |
Quality of Life (growth rate, %) | 0.813 | 0.751 | 0.062 (+8.3%) |
Quality adjusted life years | 3,399,191 | 3,138,946 | 260,245 |
Health Resource Utilisation (n) | 20,818,175 | 26,853,745 | −6,035,571 |
Physician visits (n) | 17,881,598 | 23,872,706 | −5,991,108 |
Emergency-room visits (n) | 2,871,217 | 2,893,271 | −22,054 |
Hospitalisations (n) | 65,359 | 87,768 | −22,409 |
Economic Value |
Total cost (€) | 1, 192.2 M€ | 2, 071.9 M€ | −879.6 M€ |
Community pharmacy (€) |
Community pharmacist’ service (monetary compensated and non-monetary compensated) | −352.1 M€ | 0.0 € | −352.1 M€ |
Patients | 10.0 M€ | 0.0 € | 10.0 M€ |
Cost of Health Resource Utilisation (€) |
Physician visits | 1, 198.4 M€ | 1, 599.9 M€ | −401.5 M€ |
Emergency-room visits | 206.3 M€ | 207.9 M€ | −1.6 M€ |
Hospitalisations | 134.4 M€ | 179.4 M€ | −45.0 M€ |
Other costs (€) | | | |
Medicines waste management | 14.9 M€ | 85.0 M€ | −70.1 M€ |
Syringe exchange program | −6.3 M€ | −0.3 M€ | −6.0 M€ |
Others | −13.4 M€ | 0 | −13.4 M€ |
It is estimated that current community pharmacies services represent a gain of 8.3% in QoL, providing 260,245 additional QALYs to the covered population in the year of 2014 (Table
1). The aggregated economic value provided by current services represents an added value to the society of 879.6 M€ (Table
1). This value is further divided in three main areas: 50.9% related to health care resource utilisation (448.1 M€), 38.9% from non-remunerated pharmaceutical services related with specific therapeutic areas (342.1 M€) and 10.2% from other non-remunerated pharmaceutical services with value for the society (89.5 M€). These other services comprise community pharmacists’ contributions to medicines wastage management, syringe-exchange program, voluntary participation in the
Valormed program (medicines disposal program), research projects and contributions to pharmaceutical students’ curricular internships. Together, the services on medicines wastage and syringe-exchange programs are estimated to generate a value of 76.1 M€ to society.
Previous results can be further detailed in three major health areas: chronic conditions/therapies, mother and child health and transversal services, which may have held societal values of 187.6 M€, 13.3 M€ and 589.3 M€, respectively. Services provided in chronic conditions/therapies are estimated to have a positive impact of 8.0% increment in QoL, having allowed 120,604 additional QALYs in 2014. Moreover, these sets of services are estimated to avoid 1,480,442 physician visits, 13,101 emergency-room visits and 12,962 hospitalisations. Mother and child health services are estimated to cover annually 654,285 mothers or children and to provide a 0.2% increase in QoL, with an added economic value of 13.3 M€. Evidence suggests that mother and child services do not impact health resource utilisation and therefore the economic value provided derives exclusively from non-remunerated community pharmacies services. Transversal services include services in several areas, such as non-prescription medicines counselling, multidose drug dispensing or domiciliary support. These services are estimated to increase QoL in 12.7% and hold an economic value to society of 589.3 M€ (266.3 M€ in non-remunerated community pharmacies services and 323.0 M€ in avoided costs with health resource utilisation). In this specific setting (transversal services), a total of 4,510,665 physician visits, 8953 emergency-room visits and 9446 hospitalisations were estimated to have been avoided due to community pharmacies services.
Potential future services
Pharmaceutical services potentially considered in the near future but not yet provided in community pharmacies, such as, repeat dispensing, patient call-back systems or medication reconciliation (from inpatient to outpatient setting) were also evaluated.
Overall future community pharmacies services may increase QoL by 6.9% in 1,724,274 additional patients to be potentially covered (16.6% of the Portuguese population). This increment could possibly be translated in 75,640 additional QALYs. Moreover, it could eventually have an impact on health resource consumption, avoiding 363,608 physician visits, 39 emergency-room visits and 39 hospitalisations. The added economic value of the broader range of potential future community pharmacies services may achieve 144.8 M€ (Table
2).
Table 2
Social and economic value of the future community pharmacies services
Population Covered (n) | 1,724,274 | 1,724,274 | 0 |
Estimated number of pharmaceutical services (n) | 46,870,802 | 0 | 46,870,802 |
Time spent in services (hours) | 3,807,870 | 0 | 3,807,870 |
Social Value |
Quality of Life |
Quality of Life (growth rate, %) | 0.684 | 0.640 | 0.044 (+6.9%) |
Quality adjusted life years | 1,178,882 | 1,103,242 | 75,640 |
Health Resource Utilisation (n) | 8,079,565 | 8,443,250 | −363,685 |
Physician visits (n) | 6,848,352 | 7,211,960 | −363,608 |
Emergency-room visits (n) | 1,215,835 | 1,215,873 | −38 |
Hospitalisations (n) | 15,379 | 15,417 | −38 |
Economic Value |
Total cost (€) | 458.1 M€ | 602.9 M€ | −144.8 M€ |
Community pharmacy (€) |
Community pharmacist’ service (monetary compensated and non-monetary compensated) | −120.3 M€ | 0 € | −120.3 M€ |
Patients | 0 € | 0 € | 0 € |
Cost of Health Resource Utilisation (€) |
Physician visits | 459.0 M€ | 483.3 M€ | −24.4 M€ |
Emergency-room visits | 87.4 M€ | 87.4 M€ | 0.0 M€ |
Hospitalisations | 32.1 M€ | 32.2 M€ | −0.1 M€ |
The evaluation of the potential future services can be further divided in three categories: integration with primary care, integration with secondary care and transversal services.
Integration with primary care could lead to an increase in QoL by 4.0% and a gain of 23,116 additional QALYs. The estimated economic value provided to society could sum up to 110.2 M€, which is the result of 102.5 M€ in non-remunerated pharmaceutical services, 7.7 M€, 2.8 thousand € and 81.721 thousand € in avoided physician visits, emergency-room visits and hospitalisations, respectively.
Integration with secondary care contemplated the possibility of community pharmacies to dispense medicines currently dispensed exclusively at hospital pharmacies or to adjust dosing regimens in anticoagulation therapy, among others. These sets of services are estimated to increase by 10.2% the QoL of the potentially covered population (835,703 patients) and to add 52,309 QALYs. The economic value provided to society could be the result of non-remunerated community pharmacies services (11.0 M€) and prevented physician visits (16.7 M€), summing 27.7 M€. Finally, transversal services might benefit the society in 6.8 M€ and lead to a 1.1% increase in 26,185 patients’ QoL.
Discussion
From 2011 until 2014, Portugal was subject to an international financial assistance program which led to the implementation of several austerity measures impacting the socio-economic conjecture of the country [
40]. The Portuguese National Health Service has recently celebrated 35 years of existence, health policy challenges to sustain the basic principles of its foundation – universal and general coverage, equity in access and tending towards free services – have been in the horizon [
41]. In order to preserve such values, it is urgent to efficiently allocate resources and to promote structural reforms in health care services.
Community pharmacists already play a crucial role in Public Health and their widespread network of services is an important asset in access to healthcare. Therefore, the purpose of this study was to estimate the social and economic value of current and potential future community pharmacies services in health care, in Portugal.
From the social perspective, the current estimated annual value of pharmaceutical services in the community is an overall increment in QoL of 8.3%, representing 260,245 additional QALYs. Moreover, potential future services could be accountable for an additional increase of 6.9% in QoL and 75,650 QALYs.
The economic value of community pharmacies services was demonstrated by the generated 879.6 M€ savings, attributable mainly to the health resource utilisation averted and the non-remunerated services of pharmacists. Putting these results into context, the generated 879.6 M€ savings represented 5.6% of the Portuguese Public Health expenditure and 0.5% of the GDP, in 2014 [
3]. Savings could amount to more 144.8 M€ if one considers the potential future integration of community pharmacies in primary and secondary care services and other transversal services.
This is the first study that has ever suggested social and economic value for nationwide services of community pharmacies. Previously published systematic reviews also demonstrated clinical, social and economic benefits of specific community pharmacies services worldwide [
16,
18,
42‐
44]. Overall assessment produced a positive impact on clinical, social and economic endpoints, which is in line with the present study results. Most international studies, focused on particular diseases or conditions, showed favourable results in clinical endpoints such as glycated haemoglobin, lipid parameters or blood pressure [
11‐
13,
21,
45], which was concordant with other Portuguese published studies [
46‐
51]. These studies reported mainly outcomes in patients with diabetes, hypertension, dyslipidaemia, asthma or COPD. For example, a meta-analysis of pharmaceutical services showed a decrease in glycated haemoglobin of 1.8%, whereas this study conducted in Portugal suggest a reduction of 0.7%; and for systolic and diastolic blood pressure, this meta-analysis presented a mean decrease of 7.8 mmHg and 2.9 mmHg, respectively, which were higher than the reductions considered in this study of 3.4 mmHg and 1.5 mmHg, respectively [
17,
48]. Services in weight management, smoking cessations or adherence by both national and international literature were reported in other studies and also evaluated in this economic model [
49,
52,
53]. A recent systematic review of cost-effectiveness of professional pharmacy services concluded that community pharmacies services may improve patients’ health with a beneficial economic impact to health care systems, which was in line with the current study [
44].
Throughout the literature review it was noteworthy the surplus of studies conducted in the United Stated of America (USA), in comparison with other countries. In fact, USA was pioneer in implementing a set of measures to acknowledge community pharmacies and their role in providing pharmaceutical care, such as the possibility for flu vaccine administration and other health care programmes [
18,
54]. This set of measures promotes the integration of pharmacists in the health care team and advocates for the provision of pharmaceutical care [
17]. Another study conducted in Ireland showed that favourable policy incentives may lead to a better quality of pharmaceutical services [
55], reinforcing the contribution of each countries’ pharmaceutical policies in promoting services with great value to the health care system.
Being a pioneer research in this field, this study bears limitations and caveats that must be addressed. First of all, community pharmacies services have existed for several decades. Hence, a scenario which simulates the absence of pharmaceutical services is almost impossible to achieve, and so no natural comparator scenario was possible. On the other hand, this study also anticipated some of the consequences that hypothetical future services might have in health care.
Despite the assumptions associated with future services, it is important to point out that some of the included services had already been provided or piloted in Portugal and others are already delivered in other countries. In the latter case, simulations were supported by studies previously conducted in other countries and validated by the expert panel. As such, results presented must be interpreted having these limitations into consideration.
Throughout the conducted literature review, there was a limited availability of studies reporting QoL and health resource utilisation. Moreover, it was observed that the likelihood of reporting QoL and economic data was associated with the robustness of the service that was consequently associated with positive outcomes, which in itself may be a source of bias [
11,
12,
21]. Despite this limitation, data retrieved from internationally performed services were always subjected to expert validation, in order to adjust data to the Portuguese context.
Published evidence of pharmaceutical care is mostly derived from USA [
17,
18,
56], whose health care system presents major differences in comparison with Europe. Nevertheless, accounted differences regarding health resource consumption were adjusted to the Portuguese context by national expert physicians. Also, costs associated with health resource utilisation were exclusively retrieved from national sources.
Despite the limitations, the expert panel was granted the possibility to exclude services not considered relevant in the national setting. Consequently, the developed model included exclusively pertinent services provided by Portuguese community pharmacists, validated by Portuguese experts, which could reduce the potential impact that outcomes of services conducted internationally might have when transposed to the national context.
Furthermore, this study evaluated, simultaneously, a substantial amount of services from three major perspectives: clinical, social and economic. The definition of clinical outcomes allowed a micro evaluation of each service separately. Further aggregation and comparison of services was possible due to the inclusion of macro outcomes, such as QoL (social) and costs associated with health resource utilisation (economic).
Another accounted advantage was the contribution of CEFAR that provided real-world data on services conducted and prices charged to the patients, within a representative sample of community pharmacies (more than 75% of Portuguese community pharmacies). Although much of the research conducted by CEFAR was not published, it represents the national reality and may reduce the impact of publication bias.
Moreover, the cost of pharmaceutical activities and time spent with services used to estimate non-remunerated pharmaceutical services were retrieved from previously conducted studies in Portugal with a representative sample of community pharmacies, reducing the potential impact that services led elsewhere could have had on the developed model [
33‐
35].
Further studies with sound clinical, social and economic outcomes are needed in order to build a growing body of evidence of cost-effectiveness of community pharmacies services. Accurate real-world studies, with control groups, evaluating clinical, social and/or economic outcomes of pharmaceutical services in several therapeutic areas, for instance, diabetes, hypertension, asthma or dyslipidaemia, should be promoted in order to update the current model with services conducted in the Portuguese real-life context and real-world data.
In 2007, the Portuguese legislation recognised community pharmacies as adequate sites to provide pharmaceutical services, allowing several services to be provided by community pharmacists [
57,
58]. In 2014, an agreement between National Association of Pharmacies and the Ministry of Health established several services such as the restart of the syringe-exchange program in community pharmacies, and the promotion of medication adherence in diabetes patients to promote Public Health [
59]. More recently, the government has established the intention to enhance community pharmacies services in order to promote the rational utilisation of medicines, close relationship with the National Health System and delegate services currently available at hospital level, namely the supply of medicines for oncology and transmissible diseases, currently exclusively available at hospital pharmacies [
32].