[Cost-effectiveness and cost calculation in an intervention on medication-related problems in primary care]

Evaluation of a pharmacist-led intervention to reduce drug-related problems in patients included in a home healthcare program: study protocol for a pragmatic randomized clinical trial

BACKGROUND

ATDOM is the Catalan home healthcare program at primary care level. Patients in the home care program are usually frail, elderly people with multiple comorbidities. They are often polymedicated, leading to a high risk of drug-related problems (DRPs). Our hypothesis is that the pharmacist-led individualized review of the pharmacotherapeutic plans of ATDOM patients will be effective in improving the quality of treatments by reducing DRPs in terms of indication, adequacy, effectiveness, and safety.

METHODS

Aim: To compare the effectiveness of a standardized pharmaceutical intervention for the review and optimization of pharmacological treatments in ATDOM patients with usual management practice.

DESIGN

Pragmatic randomized clinical trial with a comparable control group, with prospective follow-up regarding the intervention on the adequacy of the pharmacological treatment of patients in the ATDOM program.

SETTING

Primary care teams in the Camp de Tarragona Primary Care Area, Tarragona, Spain.

PARTICIPANTS

Four hundred and thirty-two ATDOM patients will be recruited, those who are over 65 years old and who are currently undergoing pharmacological treatment.

MEASURES

Effectiveness of a six-month long intervention in reducing DRPs per patient and polypharmacy. Additionally, in the intervention group we will evaluate the implementation of the proposals for change or improvement made by the responsible physician.

ANALYSIS

The outcomes will be analyzed on an intent-to-treat basis and the analysis units will be the individual patients. Logistic regression and linear regression models will be used to evaluate the effects of the intervention on dichotomous and continuous variables versus the control arm.

ETHICS

The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAPJGol), Barcelona, (19/141-P).

DISCUSSION

If the results of the pharmaceutical intervention are favorable, widespread implementation of the program could be possible. It could be extended to all ATDOM patients or outpatients in general. Interdisciplinary teamwork could be strengthened as a result, which would improve the healthcare continuum.

TRIAL REGISTRATION

Retrospectively registered.

CLINICALTRIALS

gov Identifier NCT05820945; Registered 21 March, 2023.

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review

Purpose

To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy.

Methods

We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs.

Results

Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability.

Conclusion

Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Effectiveness of a drug dosing service provided by community pharmacists in polymedicated elderly patients with renal impairment--a comparative study

BACKGROUND

Drug dosing errors are common in renal-impaired patients. Appropriate dosing adjustment and drug selection is important to ensure patients' safety and to avoid adverse drug effects and poor outcomes. There are few studies on this issue in community pharmacies. The aims of this study were, firstly, to determine the prevalence of dosing inadequacy as a consequence of renal impairment in patients over 65 taking 3 or more drug products who were being attended in community pharmacies and, secondly, to evaluate the effectiveness of the community pharmacist's intervention in improving dosing inadequacy in these patients when compared with usual care.

METHODS

The study was carried out in 40 Spanish community pharmacies. The study had two phases: the first, with an observational, multicentre, cross sectional design, served to determine the dosing inadequacy, the drug-related problems per patient and to obtain the control group. The second phase, with a controlled study with historical control group, was the intervention phase. When dosing adjustments were needed, the pharmacists made recommendations to the physicians. A comparison was made between the control and the intervention group regarding the prevalence of drug dosing inadequacy and the mean number of drug-related problems per patient.

RESULTS

The mean of the prevalence of drug dosing inadequacy was 17.5% [95% CI 14.6-21.5] in phase 1 and 15.5% [95% CI 14.5-16.6] in phase 2. The mean number of drug-related problems per patient was 0.7 [95% CI 0.5-0.8] in phase 1 and 0.50 [95% CI 0.4-0.6] in phase 2. The difference in the prevalence of dosing inadequacy between the control and intervention group before the pharmacists' intervention was 0.73% [95% CI (-6.0) - 7.5] and after the pharmacists' intervention it was 13.5% [95% CI 8.0 - 19.5] (p < 0.001) while the difference in the mean of drug-related problems per patient before the pharmacists' intervention was 0.05 [95% CI( -0.2) - 0.3] and following the intervention it was 0.5 [95% CI 0.3 - 0.7] (p < 0.001).

CONCLUSION

A drug dosing adjustment service for elderly patients with renal impairment in community pharmacies can increase the proportion of adequate drug dosing, and improve the drug-related problems per patient. Collaborative practice with physicians can improve these results.

[Pharmacotherapy negative outcomes resulting in Primary Care Emergency visits]

OBJECTIVE

Our aim was to estimate the prevalence of Pharmacotherapy negative outcomes in Primary Care Emergency visits in a rural environment, and to determine their preventability and severity.

DESIGN

Descriptive study with an analytical component. SITE: Primary Care Emergency Service (SUAP), Mula. Murcia.

PATIENTS

The study consisted of 330 patients over a 33 week period.

METHOD

Number and type of Pharmacotherapy negative outcomes: Pharmacist through the data, a validated questionnaire and medical history, assessing whether there was a relationship between the medications and the patient, and the reason for going to the Primary Care Emergency. In case of suspicion of Pharmacotherapy negative outcomes the patient is reassessed by the doctor, and the Pharmacotherapy negative outcomes confirmed or not identified.

RESULTS

Of the 330 patients, 317 were evaluable. The mean age of patients was 39.63 years and 51.42% were women. The mean number of drugs used was 1.38, and 26.50% (95% CI, 21.94% -31.62%) patients were detected with Pharmacotherapy negative outcomes as a cause of visiting the Primary Care Emergency. 53.57% of the detected Pharmacotherapy negative outcomes detected as regards efficacy was 53.75%, 40.48% as regards need. More than three-quarters (77.41%; 95% CI, 67.35% -85.01%) of emergency visits caused by Pharmacotherapy negative outcomes were avoidable. In terms of severity, 92.86% of the Pharmacotherapy negative outcomes were mild.

CONCLUSIONS

One in four Mula SUAP visits are due to a Pharmacotherapy negative outcomes, and 77.41% of them are preventable.

[Assessment of pharmaceutical care for pregnant women treated in the public health system in Praia Grande, São Paulo State, Brazil]

The use of medication in primary health care has increased steadily in recent decades, thus highlighting the relevance of assessing the pharmaceutical care provided to patients in the primary care setting. This article aimed to evaluate the pharmaceutical care provided by the public system in Greater Metropolitan Santos, São Paulo State, Brazil, focusing specifically on women during gestation. Methods included secondary data analysis, document analysis, interviews with key players, and visits to health services and to the pharmaceutical supply center. Deficiencies were identified in most stages of pharmaceutical care: selection, planning, purchase, storage, distribution, and dispensing. The results suggest that in order to improve primary health care, with better access, equality, and comprehensiveness, the evaluation of pharmaceutical care should be incorporated as a routine procedure.