Economic evaluation of pharmacist-led medication reviews in residential aged care facilities

Cost savings from medication reviews in community pharmacies for nursing home residents in Estonia: a case study

BACKGROUND

The aim of this study is to assess the cost savings from medication reviews conducted for individuals living in nursing homes in Estonia. Medication reviews performed as part of the automated dose dispensing (ADD) service by community pharmacies might help identify suboptimal medicine regimens.

METHODS

We use a case study approach to identify suboptimal use of medication in treatment plans and estimate the potential cost saving from medication reviews. To achieve this, we assess 101 treatment plans submitted for medication review by nursing homes in Estonia between 2021 and 2023. Additionally, we run OLS regressions to identify the most important determinants of medication cost savings.

RESULTS

We estimate an average direct cost saving of €43.62 per patient per year, which corresponds to 8.27% of the average annual medication costs. If medication reviews were conducted for all elderly individuals over 75 years old who use six or more prescription medicines, nearly 2% of Estonia's pharmaceutical budget could be saved. Regression analysis indicates that the most significant contributors to these cost savings are suboptimal use of generics, incorrect dosages (too high), and the elimination of incorrect medications.

CONCLUSIONS

Our study suggests that annual medication reviews conducted as part of the ADD service might help reduce medication expenditure when offered to a wider public.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Exploring medication safety structures and processes in nursing homes: a cross-sectional study

BACKGROUND

Medication safety is important to limit adverse events for nursing home residents. Several factors, such as interprofessional collaboration with pharmacists and medication reviews, have been shown in the literature to influence medication safety processes.

AIM

This study had three main objectives: (1) To assess how facility- and unit-level organization and infrastructure are related to medication use processes; (2) To determine the extent of medication safety-relevant processes; and (3) To explore pharmacies' and pharmacists' involvement in nursing homes' medication-related processes.

METHOD

Cross-sectional multicenter survey data (2018-2019) from a convenience sample of 118 Swiss nursing homes were used. Data were collected on facility and unit characteristics, pharmacy services, as well as medication safety-related structures and processes. Descriptive statistics were used.

RESULTS

Most of the participating nursing homes (93.2%) had electronic resident health record systems that supported medication safety in various ways (e.g., medication lists, interaction checks). Electronic data exchanges with outside partners such as pharmacies or physicians were available for fewer than half (10.2-46.3%, depending on the partner). Pharmacists collaborating with nursing homes were mainly involved in logistical support. Medication reviews were reportedly conducted regularly in two-thirds of facilities.

CONCLUSION

A high proportion of Swiss nursing homes have implemented diverse processes and structures that support medication use and safety for residents; however, their collaboration with pharmacists remains relatively limited.

A systematic review on the impact of pharmacist-provided services on patients' health outcomes in Arab countries

WHAT IS KNOWN AND OBJECTIVE

The pharmacist's role has evolved dramatically over the last few decades and shows considerable impact globally. The aim of this systematic review was to describe the nature and extent of studies evaluating the impact of pharmacist-provided services on clinical, humanistic and economic outcomes in different healthcare settings across the Arab world.

METHODS

A systematic literature search was conducted using the following databases from their inception until June 2020: Cochrane, Embase, MEDLINE, PubMed, ScienceDirect and Scopus. Reporting was done according to PRISMA guidelines, and the quality assessment utilized the Mixed Methods Appraisal Tool.

RESULTS AND DISCUSSION

Thirty-five eligible studies were included in this review, the majority of which were randomized controlled trials (RCT) (n = 26) conducted in hospital settings (n = 26). Most of the studies involved patients with specific medical conditions (n = 29) and pharmacist's interventions involved mainly medication therapy management (n = 32), counselling and education (n = 29), and medication therapy recommendations (n = 12). Several studies showed a positive impact (i.e., a statistically and/or clinically significant difference in favour of pharmacist-provided care or intervention) of pharmacist-provided services on clinical (n = 28), humanistic (n = 6) and economic (n = 5) outcomes. Conversely, five studies showed neutral or mixed effect of pharmacist interventions on clinical and humanistic outcomes.

WHAT IS NEW AND CONCLUSION

The findings of this systematic review demonstrate a positive impact of pharmacist-provided services on clinical, humanistic and economic outcomes across diverse settings in the Arab world. Most of the included studies evaluated clinical outcomes and were from hospital setting. Directed approaches are needed to advance pharmacy practice across various healthcare settings in the Arab world.

A Systematic Review of Nudge Interventions to Optimize Medication Prescribing

Background: The benefits of medication optimization are largely uncontroversial but difficult to achieve. Behavior change interventions aiming to optimize prescriber medication-related decisions, which do not forbid any option and that do not significantly change financial incentives, offer a promising way forward. These interventions are often referred to as nudges.

Objective: The current systematic literature review characterizes published studies describing nudge interventions to optimize medication prescribing by the behavioral determinants they intend to influence and the techniques they apply.

Methods: Four databases were searched (MEDLINE, Embase, PsychINFO, and CINAHL) to identify studies with nudge-type interventions aiming to optimize prescribing decisions. To describe the behavioral determinants that interventionists aimed to influence, data were extracted according to the Theoretical Domains Framework (TDF). To describe intervention techniques applied, data were extracted according to the Behavior Change Techniques (BCT) Taxonomy version 1 and MINDSPACE. Next, the recommended TDF-BCT mappings were used to appraise whether each intervention applied a sufficient array of techniques to influence all identified behavioral determinants.

Results: The current review located 15 studies comprised of 20 interventions. Of the 20 interventions, 16 interventions (80%) were effective. The behavior change techniques most often applied involved prompts (n = 13). The MINDSPACE contextual influencer most often applied involved defaults (n = 10). According to the recommended TDF-BCT mappings, only two interventions applied a sufficient array of behavior change techniques to address the behavioral determinants the interventionists aimed to influence.

Conclusion: The fact that so many interventions successfully changed prescriber behavior encourages the development of future behavior change interventions to optimize prescribing without mandates or financial incentives. The current review encourages interventionists to understand the behavioral determinants they are trying to affect, before the selection and application of techniques to change prescribing behaviors.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42020168006].

The Report of the 2020-2021 Professional Affairs Standing Committee: Pharmacists' Unique Role and Integration in Healthcare Settings

EXECUTIVE SUMMARY The 2020-21 Professional Affairs Committee was charged to (1) Read all six reports from the 2019-20 AACP standing committees to identify elements of these reports that are relevant to the committee's work this year; (2) Identify opportunities and models of integration of pharmacist care services in physician and other health provider practices beyond primary care; (3) Differentiate and make the case for the integration of pharmacist care services from that of other mid-level providers; and (4) From the work on the aforementioned charges, identify salient activities for the Center To Accelerate Pharmacy Practice Transformation and Academic Innovation (CTAP) for consideration by the AACP Strategic Planning Committee and AACP staff. This report provides information on the committee's process to address the committee charges, describes the rationale for and the results from a call to colleges and schools of pharmacy to provide information on their integrating pharmacist care services in physician and other health provider practices beyond primary care practice, and discusses how pharmacist-provided patient care services differ from those provided by other healthcare providers. The committee offers a revision to a current association policy statement, a proposed policy statement as well as recommendations to CTAP and AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

Considerations of Australian community pharmacists in the provision and implementation of cognitive pharmacy services: a qualitative study

Background

Australian federally-funded cognitive pharmacy services (CPS) (e.g. medication management and reconciliation services) have not been translated into practice consistently. These health services are purportedly accessible across all Australian community pharmacies, yet are not delivered as often as pharmacists would like. There are international indicators that pharmacists lack the complete behavioural control required to prioritise CPS, despite their desire to deliver them. This requires local investigation.

Objective

To explore Australian pharmacists’ perspectives [1] as CPS providers on the micro level, and [2] on associated meso and macro level CPS implementation issues.

Methods

Registered Australian community pharmacists were recruited via professional organisations and snowball sampling. Data were collected via an online demographic survey and semi-structured interviews until data saturation was reached. Interview transcripts were de-identified then verified by participants. Content analysis was performed to identify provider perspectives on the micro level. Framework analysis using RE-AIM was used to explore meso and macro implementation issues.

Results

Twenty-three participants across Australia gave perspectives on CPS provision. At the micro level, pharmacists did not agree on a single definition of CPS. However, they reported complexity in interactional work and patient considerations, and individual pharmacist factors that affected them when deciding whether to provide CPS. There was an overall deficiency in pharmacy workplace resources reported to be available for implementation and innovation. Use of an implementation evaluation framework suggested CPS implementation is lacking sufficient structural support, whilst reach into target population, service consistency and maintenance for CPS were not specifically considered by pharmacists.

Conclusions

This analysis of pharmacist CPS perspectives suggests slow uptake may be due to a lack of evidence-based, focused, multi-level implementation strategies that take ongoing pharmacist role transition into account. Sustained change may require external change management and implementation support, engagement of frontline clinicians in research, and the development of appropriate pharmacist practice models to support community pharmacists in their CPS roles.

Trial registration

This study was not a clinical intervention trial. It was approved by the University of Technology Sydney Human Research Ethics Committee (UTS HREC 19–3417) on the 26th of April 2019.

Residential Medication Management Reviews and continuous polypharmacy among older Australian women

Background Polypharmacy is an important consideration for the provision of Residential Medication Management Reviews (RMMRs) among older women given their enhanced risk of medication-related problems and admission to residential aged care (RAC). Objectives To determine the prevalence of the use of RMMRs among older women in RAC, and the association between RMMRs and polypharmacy, medications, and costs. Setting Older Australian women aged 79-84 years in 2005 who had at least one Medicare Benefits Schedule and Pharmaceutical Benefits Scheme record, received a service in aged care, and consented to data linkage. Methods Generalised estimating equations were used to determine the association between polypharmacy and RMMRs, while adjusting for confounding variables. Main outcome measures Prevalence of the use of RMMRs among older women in RAC, association between RMMRs and polypharmacy, medications, and costs. Results Most participants did not have continuous polypharmacy and did not receive RMMRs from 2005 [451 (67.4%)] until 2017 [666 (66.6%)]. Participants with continuous polypharmacy were 17% more likely to receive a RMMR (risk ratio 1.17; 95% confidence interval 1.11, 1.25). Participants in their final year of life and residing in outer regional/remote/very remote Australia were less likely to receive RMMRs. Out-of-pocket medication costs increased over time, and alendronate and aspirin were common contributors to polypharmacy among participants who received RMMRs. Conclusion Polypharmacy was associated with receiving RMMRs and around two-thirds of women who are entitled to a RMMR never received one. There is potential to improve the use of medicines by increasing awareness of the service among eligible individuals, their carers and health care professionals.

Cost-utility analysis of a consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients

BACKGROUND

Growing evidence shows the effects of psychotropic drugs on the evolution of dementia. Until now, only a few studies have evaluated the cost-effectiveness of psychotropic drugs in institutionalized dementia patients. This study aims to assess the cost-utility of intervention performed in the metropolitan area of Barcelona (Spain) (MN) based on consensus between specialized caregivers involved in the management of dementia patients for optimizing and potentially reducing the prescription of inappropriate psychotropic drugs in this population. This analysis was conducted using the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing (MAFEIP) tool.

METHODS

The MAFEIP tool builds up from a variety of surrogate endpoints commonly used across different studies in order to estimate health and economic outcomes in terms of incremental changes in quality adjusted life years (QALYs), as well as health and social care utilization. Cost estimates are based on scientific literature and expert opinion; they are direct costs and include medical visits, hospital care, medical tests and exams and drugs administered, among other concepts. The healthcare costs of patients using the intervention were calculated by means of a medication review that compared patients' drug-related costs before, during and after the use of the intervention conducted in MN between 2012 and 2014. The cost-utility analysis was performed from the perspective of a health care system with a time horizon of 12 months.

RESULTS

The tool calculated the incremental cost-effectiveness ratio (ICER) of the intervention, revealing it to be dominant, or rather, better (more effective) and cheaper than the current (standard) care. The ICER of the intervention was in the lower right quadrant, making it an intervention that is always accepted even with the lowest given Willingness to Pay (WTP) threshold value (€15,000).

CONCLUSIONS

The results of this study show that the intervention was dominant, or rather, better (more effective) and cheaper than the current (standard) care. This dominant intervention is therefore recommended to interested investors for systematic application.

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study

Objectives: Adverse drug events (ADE) are a common cause of morbidity and mortality in elderly patients. In this study, we assessed the impact of multidisciplinary medication review (MMR) for nursing home residents on patient safety and costs incurred by the hospital and the national health service. Methods: Medical files of residents were retrospectively assessed for medications prescribed in the previous six months. A pharmacist reviewed the prescriptions and suggested modifications to the patient's medical team. Patients were followed for six months. Trivalle's ADE geriatric risk score was calculated before and after MMR, as were number of potentially inappropriate medications, and economic impact from the perspective of the health care system and the nursing home. Results: Forty-nine patients were recruited. ADE score dropped one risk level (median score of 4 before versus 1 after, p < 0.0001). The number of patients taking at least one potentially inappropriate medication decreased from 30.6% before to 6.1% after MMR (p = 0.005). A mean saving of €232 per patient was made from the nursing home perspective following MMR (p = 0.008). Conclusion: The MMR reduced the iatrogenic drug risk for elderly residents and costs from the nursing home perspective, particularly drug expenditure.

Economic Impact of Pharmacist-Participated Medication Management for Elderly Patients in Nursing Homes: A Systematic Review

This systematic review examined the varied studies that have assessed the economic impact of pharmacist-participated medication management for nursing home residents older than 65 years of age. The articles published during 1990-2017 were found through PubMed, EMBASE and Ovid Medline. After the selection process by independent reviewers, a total of 12 studies were included. The quality of the selected articles was assessed using the Effective Public Health Practice Project checklist for economic studies. The articles were highly heterogeneous in terms of study design, pharmacist participation type, and measures of economic outcome. Therefore, the results are presented narratively according to the type of pharmacist involvement featured in the articles: interprofessional networks, interprofessional coordination, or interprofessional teamwork. Of the eight studies performing statistical comparison analyses, one study of interprofessional coordination and three of interprofessional teamwork showed statistically significant positive economic outcomes. The remaining four studies showed non-significant tendencies towards favorable economic outcomes. This review provides insights into the essential features of successful pharmacist-participated medication management for elderly patients in nursing homes.

Effect of pharmacist intervention on blood conservation therapy in total knee arthroplasty: A retrospective, observational study

BACKGROUND

Total knee arthroplasty (TKA) is associated with blood loss and an increased risk of transfusion. Guidelines for antifibrinolytic drug tranexamic acid (TXA) treatment in TKA patients are available. We evaluated the effects of anticoagulant pharmacist intervention on perioperative blood conservation treatment in TKA patients.

METHODS

In a retrospective, observational experimental study, patients admitted for TKA were allocated into the control or pharmacist intervention group. In the intervention phase, multiple interventions of TXA treatment based on guidelines were implemented. The primary endpoint was blood loss. Other outcome included postoperative haemoglobin and haematocrit levels, allogeneic blood transfusion, cost savings and safety.

RESULTS

A total of 177 patients were included (88 and 89 in the control and intervention group, respectively). In the intervention group, 24.72% orders of TXA dosage, 20.22% orders of drug choice, 26.97% orders of TXA timing and 30.34% orders of TXA administration manner were adjusted. Eighty-nine (100%) patients received blood conservation therapy compared with 21 (23.86%) patients in the control group (P < 0.001). Total blood loss was 1133.31 ± 627.08 mL in the control group compared with 604.34 ± 459.09 mL in the intervention group (P < 0.001). Postoperative drops in haemoglobin and haematocrit in the control group were greater than in the intervention group (P < 0.001). The rate of allogeneic blood transfusion was 40.91% in the control group compared with 21.35% in the intervention group (P = 0.01). Pharmacist intervention was conducted to cost savings resulting from reduced transfusion, but with comparable safety profile.

CONCLUSIONS

Anticoagulant pharmacist intervention on blood conservation treatment of TKA patients leads to favourable clinical and economic outcome.

Association of Focused Medication Review With Optimization of Psychotropic Drug Prescribing: A Systematic Review and Meta-analysis

IMPORTANCE

Medication review has been proposed to achieve improved use of psychotropic drugs, but benefits have not been confirmed.

OBJECTIVE

To synthesize evidence for focused psychotropic medication review in medication optimization.

DATA SOURCES

Medline, PsycINFO, EMBASE, and CINAHL Plus were searched from inception to February 2018 using the index terms "drug utilization review" and "psychotropic drugs" and synonyms. Additional articles were retrieved using citation tracking and reference checking.

STUDY SELECTION

Full-length, peer-reviewed articles that reported focused psychotropic medication review were included. Inclusion was determined against prespecified criteria and assessed independently.

DATA EXTRACTION AND SYNTHESIS

Study quality was assessed using National Institutes for Health appraisal tools and informed a structured synthesis of results. Meta-analysis using a random effects model was conducted.

MAIN OUTCOMES AND MEASURES

Change in the number or dosage of psychotropic medications, change in clinical parameters, change in patient-reported outcomes, and economic data were collected.

RESULTS

A total of 26 studies met the inclusion criteria. Four studies were randomized clinical trials (n = 712 participants), while the remainder were before-after studies (n = 7844 participants). Most studies were conducted in elderly individuals, people with dementia, and adults with intellectual disability. Focused psychotropic medication review is a complex intervention; the professional(s) involved, target drug, degree of integration with usual care, and participant involvement varied greatly among the studies. Meta-analysis included 3 studies (n = 652 participants). Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control (pooled odds ratio, 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment living in nursing homes. Before-after studies consistently reported a change in psychotropic drug prescribing after medication review, regardless of the population. Studies that reported the effects of psychotropic medication review on clinical outcomes failed to demonstrate benefit. Economic implications of focused psychotropic medication review were not adequately assessed. The quality of evidence is poor and studies are at risk of bias.

CONCLUSIONS AND RELEVANCE

Focused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit. More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group.