Cost-utility analysis of a pharmacotherapy follow-up for elderly nursing home residents in Spain

Cost-effectiveness of a Province-wide Quality Improvement Initiative for Reducing Potentially Inappropriate Use of Antipsychotics in Long-Term Care in British Columbia, Canada

BACKGROUND

Potentially inappropriate use of antipsychotics (PIUA) raises serious concerns about safety, quality, and cost of care for residents in long-term care (LTC).

OBJECTIVE

This study aimed to estimate the cost-effectiveness of the Call for Less Antipsychotics in Long-Term Care (Clear) initiative compared with the status quo (pre-Clear, baseline).

METHODS

A model-based cost-utility analysis, from a public-payer perspective in British Columbia, was conducted using secondary data of residents in LTC homes from 2013 to 2019. Residents' health resource utilization and quality-adjusted life-year (QALY) measures were extracted from multiple administrative databases. Six Markov states were modelled for post-antipsychotic progression representing PIUA, appropriate use of antipsychotic, complete withdrawal, and death. The primary outcome was the incremental cost per QALY gained.

RESULTS

A cohort of 35,669 residents was included in the primary analysis. The Clear initiative, over 10 years, was estimated to have an incremental cost-effectiveness ratio (ICER) of CA$26,055 (2020 Canadian dollars) per QALY gained at an incremental cost of CA$5211 per resident and a QALY gain of 0.20. In the subgroup analyses, our findings were even more favourable for Clear wave 2 (ICER of CA$24,447 per QALY gained) and Clear wave 3 (ICER of CA$25,933 per QALY gained). At a willingness-to-pay of CA$50,000 per QALY gained, the probabilities of Clear waves 2 and 3 were 82% cost-effective.

CONCLUSION

This study demonstrated incremental costs and yielded favourable ICERs for Clear compared with the baseline. More research is needed to understand the level of support for individual care homes to sustain the Clear initiative in the long run.

Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients

BACKGROUND

Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results.

METHODS

A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials.

RESULTS

Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention.

CONCLUSIONS

It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.

Evaluating an implementation programme for medication review with follow-up in community pharmacy using a hybrid effectiveness study design: translating evidence into practice

OBJECTIVES

To evaluate an implementation programme of a community pharmacy medication review with follow-up (MRF) service using a hybrid effectiveness-implementation study design, and to compare the clinical and humanistic outcomes with those in a previously conducted cluster randomised controlled trial (cRCT).

SETTING

Community pharmacies in Spain.

PARTICIPANTS

135 community pharmacies and 222 pharmacists providing MRF to polymedicated patients aged 65 or over.

INTERVENTION

The intervention was an implementation programme for the MRF service. A national level group was established, mirrored with a provincial level group. A series of interventions were defined (1) to engage pharmacy owners with the implementation model and (2) to provide training to pharmacists consisting of clinical case studies, process of MRF, communication skills and data collection methods and (3) practice change facilitators.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes for the implementation programme were progress, reach, fidelity and integration. The secondary outcomes were number of medications, non-controlled health problems, emergency visits, hospitalisations and health-related quality of life, which were compared with a previous 6-month cluster RCT.

RESULTS

55% of pharmacies reached the implementation phase and 35.6% remained in the testing phase at 12 months. A reach of 89.3% (n=844) was achieved. Fidelity average score was 8.45 (min: 6.2, max: 9.3) out of 10. The integration mean score was 3.39 (SD: 0.72) out of 5. MRF service outcomes were similar to the cluster RCT study; however, the magnitude of the outcomes was delayed.

CONCLUSIONS

The implementation of pharmacy services is a complex multifactorial process, conditioned by numerous implementation factors. In the absence of remuneration, the implementation of the MRF service is a slow process, taking at least 12 months to complete.

TRIAL REGISTRATION NUMBER

CGFTRA-2017-01.

Clinical and cost effectiveness of a multi-professional medication reviews in care homes (CAREMED)†

Objectives

With 70% of care home residents experiencing a medication error every day in the UK, better multi-professional working between medical practitioners, pharmacists and care homes was recommended. The aim of this study was to determine the effectiveness (falls reduction) and cost-effectiveness, of a multi-professional medication review (MPMR) service in care homes for older people.

Method

A total of care homes in the East of England were cluster randomised to ‘usual care’ or two multi-professional (General practitioner, clinical pharmacist and care homes staff) medication reviews during the 12-month trial period. Target recruitment was 900 residents with 10% assumed loss to follow-up. Co-primary outcome measures were number of falls and potentially inappropriate prescribing assessed by the Screening Tool of Older Persons Prescriptions.

Key findings

A total of 826 care home residents were recruited with 324 lost to follow-up for at least one primary outcome measure. The mean number of falls per resident per annum was 3.3 for intervention and 3.0 for control (P = 0.947). Each resident was found to be prescribed 0.69 (intervention) and 0.85 (control) potentially inappropriate medicines after 12 months (P = 0.046). No significant difference identified in emergency hospital admissions or deaths. Estimated unadjusted incremental mean cost per resident was £374.26 higher in the intervention group.

Conclusions

In line with other medication review based interventions in care homes, two MPMRs improved medication appropriateness but failed to demonstrate improvements in clinical outcomes. From a health system perspective costs where estimated to increase overall and therefore a different model of medicines management is required.

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process

OBJECTIVES

To develop a training programme to enable pharmacists with prescribing rights to assume responsibility for the provision of pharmaceutical care within care homes, a systematic review and narrative synthesis was undertaken to identify reported approaches to training pharmacists and use this literature to identify potential knowledge requirements.

METHODS

A PROSPERO-registered systematic review was performed using key search terms for care homes, pharmacist, education, training and pharmaceutical care. Papers reporting primary research focussed on care of the older person within the care home setting were included. No restrictions were placed on methodology. Two researchers independently reviewed titles, abstracts and papers. Agreement on inclusion was reached through consensus. Data on titles, training and activities undertaken were extracted and knowledge requirements identified. Findings were synthesised and reported narratively.

KEY FINDINGS

Fifty-nine papers were included, most of which were uncontrolled service evaluations. Four papers reported an accreditation process for the pharmacist. Thirteen papers reported providing tools or specific training on a single topic to pharmacists. The main clinical and therapeutic areas of activity (requiring codified knowledge) were dementia, pain, antipsychotic and cardiovascular medication. Provision of pharmaceutical care, effective multidisciplinary working and care home staff training represented the main areas of practical knowledge.

CONCLUSIONS

Information regarding training and accreditation processes for care home pharmacists is limited. This study provides insight into potential codified and practical knowledge requirements for pharmacists assuming responsibility for the provision of pharmaceutical care within care homes. Further work involving stakeholders is required to identify the cultural knowledge requirements and to develop a training and accreditation process.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

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.

Perspectives of Non-Pharmacy Professionals in Long-Term Care Facilities on Pharmacist-Involved Medication Management in South Korea: A Qualitative Study

Despite a rapid increase in both the number of long-term care facilities (LTCFs) and their residents in recent years, the concept of pharmacist-involved medication management is relatively new in South Korea. The objective of this study was to identify the perspectives of non-pharmacy professionals regarding the development of pharmacist-involved medication management in LTCFs. Employing a snowball sampling strategy, this study relied on semi-structured, one-on-one, in-depth interviews with twelve non-pharmacy professionals in LTCFs. The inductive thematic analysis and the constant comparative method were employed for the analysis. Participants revealed the need for pharmacist-involved medication management systems in LTCFs at the intrinsic and environmental levels. Through pharmacist-involved medication management, participants desired "medication review/reconciliation" and "pharmaceutical education/counseling". The barriers to be overcome included "the authorization of pharmacists' roles", "the financial stability of LTCFs", "role awareness among coworkers", and "the professional development of pharmacists". In this study, we advanced our understanding of non-pharmacy professionals' perceptions of pharmacist-involved medication management in LTCFs. The results of this study can be applied in other Asian countries where the development of pharmacist-involved medication management for the institutionalized elderly is relatively new.

Role and impact of pharmacists in Spain: a scoping review

Background The role of the pharmacist has evolved greatly over the last decades, expanding to patient-oriented activities, administrative tasks and public health functions. However, considerable differences emerge across regions. Aim of the review To gather evidence in order to describe and highlight the different characteristics of the pharmacists' role and the impact of their activities in Spain. Method A review of the existing literature was conducted. The literature search was undertaken in PubMed between 01/01/2006 and 15/08/2017. Results were screened and reviewed to extract previously established criteria such as author(s), publication year, language, study design, setting, pharmaceutical activity, patient care programs, targeted diseases and intervention description using DEPICT2 tool. Pharmaceutical intervention were classified into eight outcome measures and categorized by types of outcomes reported: descriptive or impact evaluation regarding the effect of the service (positive, neutral or negative). Results The search strategy resulted in 473 articles and 108 articles met the inclusion criteria. The most common design was observational (n = 76, 70%). Most articles were published after 2011 (75%), in English (69%). Studies were conducted in hospitals (60%) and community pharmacies (30%). Of the 24 pharmaceutical activities identified, medication review was the activity most frequently studied (n = 42), followed by patient education (n = 29), risk and prevention (n = 27) and medication reconciliation (n = 19). Only 39 articles (36%) had outcome measures with impact evaluation. Of the 223 impact outcome measures, 48% (107/223) had a positive effect. Conclusion This review shows the substantial scientific production focusing on pharmacy practice in Spain over the last years. The evidence reviewed reflects the pharmacist role at various professional settings, providing a wide variety of activities on diverse targeted diseases and patient care programs, in line with the increasing specialization of clinical pharmacists over the last years.

Impact of pharmaceutical care on cardiovascular risk among older HIV patients on antiretroviral therapy

Background Advances in the treatment of HIV infection have enabled better control of the disease, allowing patients to enjoy a longer life expectancy. However, the ageing of patients leads to an increased prevalence of cardiovascular disease. Various studies have found that pharmaceutical care results in better control of cardiovascular risk factors. Objective To measure the impact of pharmaceutical care on cardiovascular risk in patients older than 50 years receiving combination antiretroviral therapy. Setting Outpatient pharmacy service of a tertiary hospital, Spain. Methods A pre/post-intervention quasi-experimental clinical study was conducted in which health education and pharmacist interventions to reduce cardiovascular risk factors were carried out in a single patient cohort using the Dader method of pharmacotherapy, with a 12-month follow-up period per patient. Patients included were older than 50 years, with moderate/elevated cardiovascular risk. Data were obtained from patient clinical histories, dispensing records and patient interviews, and were subjected to statistical analysis. Main outcome measure Cardiovascular risk estimated by SCORE and REGICOR equations. Results Forty-two patients completed the study. Of these, 93 % were men, with an average age of 57 years and 15 years since diagnosis of HIV. A reduction was observed in the mean values (baseline vs. 12 months) of the following cardiovascular risk factors: systolic blood pressure (P = 0.009), diastolic blood pressure (P = 0.010), total cholesterol (P = 0.006), low-density lipoprotein cholesterol (LDL-c; P = 0.039), triglycerides (P = 0.010) and total cholesterol/high-density lipoprotein cholesterol (HDL-c; P < 0.001). An increase in HDL-c (P = 0.037) was also observed. The average cardiovascular risk estimated by the SCORE instrument was reduced from 7.6 % at the beginning of the study to 6.4 % after 12 months (P = 0.039). The risk estimate according to REGICOR also decreased (P = 0.002). Over the 12-month period, 6.3 ± 3.4 interventions were carried out per patient. Quantitative ineffectiveness was the most prevalent negative outcome associated with medication throughout the study, and noncompliance was the most frequent cause. Interventions on health education were the most common, followed by interventions on improving adherence. Conclusion Pharmaceutical care, delivered as a combination of health education and pharmacotherapy follow-up to outpatients at a tertiary hospital, had a positive impact on cardiovascular risk in patients older than 50 years receiving combination antiretroviral therapy.

Perspectives About Health Care Provision in Dementia Care in Spain: A Qualitative Study Using Focus-Group Methodology

BACKGROUND

The aim of this study is to identify the barriers and facilitators in dementia care with respect to information provision, communication, and collaboration from the perspectives of the person with dementia, family caregivers, and health care professionals over the course of the illness.

METHODS

A qualitative study using Focus-Group methodology was carried out in people with dementia, family caregivers, and health care providers.

RESULTS

The categories that emerged from the analysis were insufficient information provided, specific dementia care needs, and acceptance of long-term care institutionalization from the people with dementia and caregivers' groups and insufficient communication between health care providers, differential information according to disease stage, and home care coordination from the health care providers' groups.

CONCLUSION

The family is a key element in successful care coordination during dementia care provision. New effective strategies including self-management and emergent roles, such as case managers, could bring great benefits to people with dementia, caregivers, and health care providers.

Cost-utility analysis of a medication review with follow-up service for older adults with polypharmacy in community pharmacies in Spain: the conSIGUE program

BACKGROUND

The concept of pharmaceutical care is operationalized through pharmaceutical professional services, which are patient-oriented to optimize their pharmacotherapy and to improve clinical outcomes.

OBJECTIVE

The objective of this study was to estimate the incremental cost-effectiveness ratio (ICER) of a medication review with follow-up (MRF) service for older adults with polypharmacy in Spanish community pharmacies against the alternative of having their medication dispensed normally.

METHODS

The study was designed as a cluster randomized controlled trial, and was carried out over a time horizon of 6 months. The target population was older adults with polypharmacy, defined as individuals taking five or more medicines per day. The study was conducted in 178 community pharmacies in Spain. Cost-utility analysis adopted a health service perspective. Costs were in euros at 2014 prices and the effectiveness of the intervention was estimated as quality-adjusted life-years (QALYs). In order to analyze the uncertainty of ICER results, we performed a non-parametric bootstrapping with 5000 replications.

RESULTS

A total of 1403 older adults, aged between 65 and 94 years, were enrolled in the study: 688 in the intervention group (IG) and 715 in the control group (CG). By the end of the follow-up, both groups had reduced the mean number of prescribed medications they took, although this reduction was greater in the IG (0.28 ± 1.25 drugs; p < 0.001) than in the CG (0.07 ± 0.95 drugs; p = 0.063). Older adults in the IG saw their quality of life improved by 0.0528 ± 0.20 (p < 0.001). In contrast, the CG experienced a slight reduction in their quality of life: 0.0022 ± 0.24 (p = 0.815). The mean total cost was <euro>977.57 ± 1455.88 for the IG and <euro>1173.44 ± 3671.65 for the CG. In order to estimate the ICER, we used the costs adjusted for baseline medications and QALYs adjusted for baseline utility score, resulting in a mean incremental total cost of -<euro>250.51 ± 148.61 (95 % CI -541.79 to 40.76) and a mean incremental QALY of 0.0156 ± 0.004 (95 % CI 0.008-0.023). Regarding the results from the cost-utility analysis, the MRF service emerged as the dominant strategy.

CONCLUSION

The MRF service is an effective intervention for optimizing prescribed medication and improving quality of life in older adults with polypharmacy in community pharmacies. The results from the cost-utility analysis suggest that the MRF service is cost effective.