Pharmacoeconomics seminar
-
Upload
dr-ketan-asawalle -
Category
Health & Medicine
-
view
387 -
download
8
description
Transcript of Pharmacoeconomics seminar
![Page 1: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/1.jpg)
BASICS OF
PHARMACOECONOMICS
By Dr Ketan Asawalle
JR1,Dept. of Pharmacology
SVNGMC Yavatmal
![Page 2: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/2.jpg)
SCOPE OF
PRESENTATION
1. Introduction
2. Brief History
3. Challenges
![Page 3: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/3.jpg)
4. Pharmacoeconomic Evaluation
5. Methods for Evaluation
SCOPE OF
PRESENTATION
6. Assessment of Results
![Page 4: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/4.jpg)
SCOPE OF
PRESENTATION
7. Limitations of Evaluation
8. Summary
![Page 5: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/5.jpg)
HISTORY
![Page 6: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/6.jpg)
• Economic evaluations in the field of pharmacology started about 30 years ago
Crude parameters were used to evaluate e.g. increased labour production
• The term PHARMACOECONOMICS was used on a public forum for the first time in
![Page 7: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/7.jpg)
INTRODUCTION
![Page 8: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/8.jpg)
• Who Pays for medical bills ?
1.Government
2. Insurance Companies
![Page 9: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/9.jpg)
This NEVER
Happens
![Page 10: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/10.jpg)
This ALWAYS happens
![Page 11: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/11.jpg)
Health care Funders try to make efforts to contain drug costs
By
• Price negotiations
• Patient co-payments
• Dedicated Drug Bills
![Page 12: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/12.jpg)
WHAT IS A DRUG
BILL?
![Page 13: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/13.jpg)
![Page 14: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/14.jpg)
which states the various policies of that government that it has made for health care improvement in the country
percentage of GDP that particular country has allotted for
![Page 15: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/15.jpg)
Generally the health care bill is 10 to 15% of total GDP
In 2013, Indian health care budget was 1.04% of the GDP
In 2014 it is proposed to touch 2.5%
![Page 16: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/16.jpg)
Health Care Funders have to keenly study all these aspects in order to achieve their
SAVE AS MUCH MONEY AS POSSIBLE ALONG WITH PROVIDING ADEQUATE HEALTH CARE
![Page 17: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/17.jpg)
The VERY FIRST aspect of controlling drug costs is
EVALUATION OF EXPENDITURE OF DRUG THERAPY
![Page 18: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/18.jpg)
REASONS for EVALUATION
Size of drug bill
Easy to measure pharmaceutical costs
Evidence of wasteful prescribing
Perception that drug companies work for profits
![Page 19: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/19.jpg)
DEFINITION
![Page 20: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/20.jpg)
PHARMACOECONOMICS
effectiveness, cost-minimization, cost-of-illness and cost
![Page 21: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/21.jpg)
Pharmacoeconomics adopts and applies the principles and methodology of HEALTH ECONOMICS
![Page 22: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/22.jpg)
Pharmacoeconomic evaluation therefore makes use of the broad range of techniques used in health economics evaluation to the s
![Page 23: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/23.jpg)
Pharmacoeconomics is the description and analysis of the costs of drug therapy
![Page 24: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/24.jpg)
BASIC USES
![Page 25: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/25.jpg)
• Make formulary decisions
• Design disease management programs
• Measuring the cost- effectiveness of interventions and programs
![Page 26: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/26.jpg)
NEED FOR
PHARMACOECONOMICS
![Page 27: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/27.jpg)
GOVERNMENT
Determining programme benefits and prices paid
INDUSTRY
Deciding among specific research and development alternatives
PRIVATE SECTOR
Determining the insurance benefit
![Page 28: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/28.jpg)
COMMON MAN
![Page 29: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/29.jpg)
Rising health expenditures have led to the necessity to find the optimal therapy at the lowest price
Pharmaceutical expenditure has increased dramatically
Numerous alternatives for the same disease/condition
Increasing costs of health care products
![Page 30: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/30.jpg)
IMPORTANT
TERMS
![Page 31: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/31.jpg)
PRO i.e. PATIENT REPORTED OUTCOME
HRQL i.e. HEALTH RELATED QUALITY OF LIFE
QALY i.e. QUALITY ADJUSTED LIFE YEARS
![Page 32: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/32.jpg)
PATIENT REPORTED OUTCOME (PRO)
Measured by self-reported questioners
patients own viewpoint about the new product in question
![Page 33: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/33.jpg)
HEALTH RELATED QUALITY OF LIFE
related quality of life" (HRQL) is an individual's satisfaction or happiness with domains of life
![Page 34: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/34.jpg)
variables within the dimension of health (e.g., a disease or its treatment) relate to
![Page 35: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/35.jpg)
disease burden, including both the quality and the quantity of life lived
The quality-adjusted life year QALY
Based on the number of years of life that would be added by the
![Page 36: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/36.jpg)
CHALLENGES
![Page 37: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/37.jpg)
Training and education in ANALYSIS of DATA
Standardizing the methods and establishing GUIDELINES for practice
CONTINUED EDUCATION on relevant features
Stable FUNDS
![Page 38: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/38.jpg)
PHARMACO-ECONOMIC
EVALUATION
![Page 39: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/39.jpg)
![Page 40: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/40.jpg)
ISSUES
INPUT
COSTS PERSPECTIVES
HEALTH CARE
OUTCOME
![Page 41: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/41.jpg)
PERSPECTIVE
Gives the information about from whose point of view the evaluation is considered
1. Health Service Perspective
Two Types
2. Societal Perspective
![Page 42: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/42.jpg)
Generally the societal perspective is considered but the health mangers facing problem of low budget concentrates on health s
Health service perspective contains direct cost
Societal perspective contains indirect cost
![Page 43: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/43.jpg)
COSTS
Two main types
is the benefit foregone when selecting one therapy alternative over the next best alternative
Financial costs=Mandatory costs
Economic costs=Non mandatory costs
![Page 44: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/44.jpg)
MEASUREMENT OF COST
1.cost/unit (cost/tablet, cost/vail)
2.cost/treatment
3.cost/person
4.cost/person/year
5.cost/case prevented
6.cost/life saved
7.cost/DALY
![Page 45: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/45.jpg)
OUTCOME
What is the effect of alternative drug therapies on disease progression, survival, quality of life?
POSITIVE and NEGATIVE outcomes are to be considered
Positive outcomes = Drug Efficacy
Negative outcomes = Side Effects, Treatment failure and Drug Resistance
![Page 46: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/46.jpg)
METHODS OF
PHARMACO-ECONOMIC
EVALUATION
![Page 47: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/47.jpg)
![Page 48: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/48.jpg)
COST-MINIMIZATION
ANALYSIS
![Page 49: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/49.jpg)
• Measures only costs
• Mainly of Health Services
• Applicable only when outcomes are identical and need not be considered separately
![Page 50: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/50.jpg)
EXAMPLE
Comparing prescriptions containing generic drug and leading branded drug
Amoxicillin-clavulenic acid and Augmentin™
![Page 51: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/51.jpg)
The purpose is to project the least costly drug or treatment modality
Reflects cost of preparing and administering a drug
![Page 52: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/52.jpg)
![Page 53: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/53.jpg)
COST-EFFECTIVENESS
ANALYSIS
![Page 54: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/54.jpg)
![Page 55: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/55.jpg)
It refer to a particular type of evaluation, in which the health benefit can be defined and measured in natural units (e.g. years of life saved, ulcers healed) and the
![Page 56: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/56.jpg)
Compares the relative costs and outcomes (effects) of two or more courses of action
Assigns a monetary value to the measure of effect
CEA is
Cost associated with health measureGain of health from a measure
![Page 57: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/57.jpg)
Compares therapies with qualitatively similar outcomes in a particular therapeutic area
QALY is the most common outcome measure
![Page 58: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/58.jpg)
In severe reflux oesophagitis, we could consider the costs per patient relieved of symptoms using a
EXAMPLE
![Page 59: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/59.jpg)
COST-UTILITY
ANALYSIS
![Page 60: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/60.jpg)
Similar to Cost-effectiveness analysis
Costs are measured in Money
Outcome is Defined
Outcome is a Unit of Utility e.g. QALY
![Page 61: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/61.jpg)
End point of disease is not directly dependent in disease state
Can look into more than one area of medicine
![Page 62: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/62.jpg)
Cost per QALY of coronary artery bypass grafting versus cost per QAL Y for erythropoietin in renal disease
EXAMPLE
![Page 63: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/63.jpg)
![Page 64: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/64.jpg)
difficult than measuring the monetary value of life through health improvements
This is because in CUA you need to measure the health improvement effects for every remaining year of life
DRAWBACK
![Page 65: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/65.jpg)
COST-BENEFIT
ANALYSIS
![Page 66: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/66.jpg)
The benefit is measured as the associated economic benefit
E.g. monetary value of returning a worker to employment earlier
Both costs and benefits are expressed in money
![Page 67: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/67.jpg)
Allows comparisons to be made between very different areas, and not just medical
(benefits of improved education and hence productivity) compared to establishing a back pain service
![Page 68: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/68.jpg)
but very important benefits not measurable in money terms, e.g. relief of anxiety
CBA may also seem to discriminate against those in whom a return to productive employment is unlikely
DRAWBACKS
![Page 69: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/69.jpg)
SUMMARY
![Page 70: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/70.jpg)
RESULTS OF
EVALUATION
![Page 71: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/71.jpg)
FOUR POSSIBILITIES
New treatment is
More effective and more expensive
More effective less expensive
Less effective less expensive
Less effective more expensive
![Page 72: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/72.jpg)
RESULTS OF ECONOMIC EVALUATION
I
IIIII
IV
![Page 73: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/73.jpg)
This would be the case in which only TWO treatment regimens or drugs are considered
But what if multiple regimens are considered at once
![Page 74: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/74.jpg)
Beta Slope
![Page 75: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/75.jpg)
MARKOV’S POPULATION TREE FOR DECISION ANALYSIS
OTHER METHODS OF DECISION MAKING
AMOUNT NEEDED TO TREAT/NUMBER NEEDE TO TREAT
![Page 76: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/76.jpg)
LIMITATIONS
![Page 77: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/77.jpg)
BIAS
![Page 78: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/78.jpg)
• Choice of comparator drug
• The assumptions made
• Selective reporting of results
![Page 79: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/79.jpg)
WHY IS THIS BIAS?
![Page 80: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/80.jpg)
less well understood by doctors and others, bias needs to be minimised
Doctors may tend to equate health economics with rationing or cost cutting, and therefore may reject the whole process as
![Page 81: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/81.jpg)
MAIN PROBLEMS
• A short term outlook
• Many budgets operate in isolation, and it is not easy to move money between them
• A new intervention may simply not be affordable no matter how cost effective it might be
• Young sciences
• Need of proper guidelines
![Page 82: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/82.jpg)
THANK YOU
![Page 83: Pharmacoeconomics seminar](https://reader030.fdocuments.us/reader030/viewer/2022012908/559e23ac1a28abb9118b45b9/html5/thumbnails/83.jpg)
REFERENCES
1. A Practical Guide To Clinical Audit, Quality and Patient Safety(QPSD-D-029-1 V.1)
2 Pharmacoeconomics: basic concepts and terminology T. Walley & A. Haycox (Department of Pharmacology and Therapeutics, Univers
3. Pharmacoeconomics and Economic Evaluation of Drug Therapies Tom Walley, M.D. (Professor of Clinical Pharmacology Departmen
4. PHARMACOECONOMICS: A REVIEW SURENDRA G. GATTANI, Department of Pharmaceutics, R.C.Patel college of Pharmacy, Karwand naka, Sh
ABASAHEB B. PATIL, Lecturer Department of Pharmaceutics , R.C.P.E.R. Malegaon,
SACHIN S. KUSHARE, Department of Pharmaceutics R.C.Patel college of Pharmacy, Shirpur
5. THE THEORY OF COST-BENEFIT ANALYSIS JEAN DREZE AND NICHOLAS STERN (London School of Economics)
6. DRUG UTILIZATION AND THERAPEUTIC AUDIT, British journal of clinical pharmacology (1980), 9, 227