Assessing the value of pharmacists' health-systemwide services: clinical pathways and treatment guidelines.

Practice guidelines and clinical pathways are increasingly being used as tools to enhance the quality of health care services and to manage costs better. This article reviews the role of guidelines and clinical pathways in health care as defined within the broader concept of practice policies. The factors that increase the effectiveness of practice policies are examined. These include the origin of development, dissemination technique, and implementation strategy. Policies that are internally developed and implemented with concurrent reminder systems are the most effective. Clinical pathways fit these criteria and are therefore highly effective policy types. The roles that pharmacists within health systems can undertake in policy development are described. These include writing the policy document, providing expert review, providing education, and most important, facilitating the desired outcomes by implementing pharmacy services that promote compliance with the guidelines. Examples of pharmacy-based guideline and pathway implementation from the Henry Ford Health System are described for inpatient anticoagulation, outpatient preferred drug formulary policy, and outpatient lipid therapy management.

Cost-effectiveness of enoxaparin versus low-dose heparin for prophylaxis against venous thrombosis after major trauma.

We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. Length of hospital stay data and 1996 institutional drug use and acquisition cost data were used to estimate the cost of enoxaparin and heparin therapy. Diagnosis and treatment costs for DVT and pulmonary embolism were derived from institutional charge data using cost:charge ratios. A second analysis of patients with lower extremity fractures was completed. One-way and multiway sensitivity analyses were performed. For 1000 mixed trauma patients receiving enoxaparin versus heparin, our model showed that 62.2 (95% CI -113 to -12) DVTs or pulmonary emboli would be avoided, resulting in 67.6 (8 to 130) life-years saved at a net cost increase of $104,764 (-$329,300 to $159,600). Enoxaparin versus heparin resulted in a cost of $1684 (-$3600 to $9800) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $2303 (-$8100 to $19,000). For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.