Teaching the Tools of Pharmaceutical Care Decision-Analysis.

While there are numerous definitions of pharmaceutical care, (1-4) they all have in common an effort to assist patients and the health care delivery system in optimizing medication delivery and use. As pharmacists become more involved in the delivery of pharmaceutical care, it is vital that they develop new abilities to aid in fulfilling the increased demands that accompany the greater responsibilities undertaken by (or imposed upon) the profession. Historically, medical care decision making has concerned itself with medical outcomes. This is certainly likely to be the emphasis in traditional practices of pharmacy. In the increasingly nontraditional settings in which many pharmacists find themselves, e.g., formulary committees, traditional concerns are beginning to incorporate supplemental information concerning the economics of treatments. Whether they are directly involved in decision making about health care delivery or not, to operate in this new environment, pharmacists will need a greater understanding of how and why such decisions are made. Regardless of the basis for these decisions (solely health or supplemented by economics), a near pervasive aspect of any medical decision making is the existence of some degree of uncertainty. Many treatments have effects, both health and economic, that are not uniform across the entire patient population. The fields of epidemiology and economics attempt to reduce and quantify this uncertainty. Decision making in the face of such uncertainty is obviously more difficult than in its absence. In the engineering and business/economics fields (and increasingly in health care), techniques of decision analysis have been brought to bear in order to systematically analyze choices and assist in identifying superior alternatives when decisions must be made under conditions of uncertainty. In health care, these techniques typically meld health and economic outcomes by appealing to epidemiologic and economic evidence as inputs into decision analytic models of treatment choices. The popularity and sometimes apparent simplicity of these techniques belies their potential complexity. While these methods do assist analysts by simplifying decision making, they cannot work magic. Furthermore, the techniques have a history of sophisticated development that is not always apparent. Adapting the techniques on an ad hoc basis in a seemingly reasonable way may be wholly inappropriate. It is vital that practitioners be aware of the uses and limitations of decision analysis and the boundaries on its appropriate use. This is not always the case. The techniques must be applied intelligently and carefully. An 18th century social commentator and poet, Alexander Pope, once wrote, “A little learning is a dang’rous thing”. He could have been writing about decision analysis. The under/supply of formally trained decision analysts in the current health care analytical environment has contributed to the self-taught nature of many practitioners in the field. Unfortunately, many of the self-taught (and perhaps others) are not as acquainted with the relevant and essential literature as they need to be. Schechter(5) has indicated several examples of decision analyses in the published pharmacy health care literature which appear to have little acquaintance with proper established analytical procedures. These are not mere theoretical quibbles with methodology; in spirit they are akin to implementing arithmetic addition “theory” by assuming that two plus two equals five. Violations of the theory are simply going to give the wrong answer. The problem is that few readers (or, apparently, reviewers) are sufficiently acquainted with the methods to identify errors prior to publication. The concept of peer review takes on a new connotation in these cases. It is in part because of this state of affairs that the University of North Carolina at Chapel Hill program in Pharmacy Administration has emphasized formal training of its students by professors trained in specific disciplines like epidemiology and economics who, because of their advanced training in these disciplines, are more aware of the pitfalls that await the uninformed practitioner. While expertise is no guarantor of perfection, some of the more egregious errors of the past could have been avoided by such formal training. This article indicates the power of decision analysis in two aspects of health care decision making. It shows how epidemiology and economics may be integrated in illustrating standard epidemiologic principles with the techniques of decision analysis. It also shows how treatment choice can be informed and optimized with the appropriate melding of epidemiologic and economic evidence through such “techniques. In the right hands, decision analysis is an illuminating tool that can assist all health care providers and decision makers in optimizing health care delivery. In the wrong hands, it can provide a technocratic illusion of scientific decision making that may violate the axiom—”first do no harm.”