Cost-minimization analysis of community pharmacy-based point-of-care testing for strep throat in 5 Canadian provinces

Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020)

BACKGROUND

Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment.

AIM

To conduct a systematic review of literature on economic evaluation of pharmacy services.

METHOD

Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA).

RESULTS

Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11).

CONCLUSION

The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.

Economic Analyses of Respiratory Tract Infection Diagnostics: A Systematic Review

BACKGROUND

Diagnostic testing for respiratory tract infections is a tool to manage the current COVID-19 pandemic, as well as the rising incidence of antimicrobial resistance. At the same time, new European regulations for market entry of in vitro diagnostics, in the form of the in vitro diagnostic regulation, may lead to more clinical evidence supporting health-economic analyses.

OBJECTIVE

The objective of this systematic review was to review the methods used in economic evaluations of applied diagnostic techniques, for all patients seeking care for infectious diseases of the respiratory tract (such as pneumonia, pulmonary tuberculosis, influenza, sinusitis, pharyngitis, sore throats and general respiratory tract infections).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles from three large databases of scientific literature were included (Scopus, Web of Science and PubMed) for the period January 2000 to May 2020.

RESULTS

A total of 70 economic analyses are included, most of which use decision tree modelling for diagnostic testing for respiratory tract infections in the community-care setting. Many studies do not incorporate a generally comparable clinical outcome in their cost-effectiveness analysis: fewer than half the studies (33/70) used generalisable outcomes such as quality-adjusted life-years. Other papers consider outcomes related to the accuracy of the test or outcomes related to the prescribed treatment. The time horizons of the studies generally are limited.

CONCLUSIONS

The methods to economically assess diagnostic tests for respiratory tract infections vary and would benefit from clear recommendations from policy makers on the assessed time horizon and outcomes used.

Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation

BACKGROUND

Sore throat is a common condition caused by an infection of the airway. Most cases are of a viral nature; however, a number of these infections may be caused by the group A Streptococcus bacterium. Most viral and bacterial sore throat infections resolve spontaneously within a few weeks. Point-of-care testing in primary care has been recognised as an emerging technology for aiding targeted antibiotic prescribing for sore throat in cases that do not spontaneously resolve.

OBJECTIVE

Systematically review the evidence for 21 point-of-care tests for detecting group A Streptococcus bacteria and develop a de novo economic model to compare the cost-effectiveness of point-of-care tests alongside clinical scoring tools with the cost-effectiveness of clinical scoring tools alone for patients managed in primary care and hospital settings.

DATA SOURCES

Multiple electronic databases were searched from inception to March 2019. The following databases were searched in November and December 2018 and searches were updated in March 2019: MEDLINE [via OvidSP (Health First, Rockledge, FL, USA)], MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP), MEDLINE Epub Ahead of Print (via OvidSP), MEDLINE Daily Update (via OvidSP), EMBASE (via OvidSP), Cochrane Database of Systematic Reviews [via Wiley Online Library (John Wiley & Sons, Inc., Hoboken, NJ, USA)], Cochrane Central Register of Controlled Trials (CENTRAL) (via Wiley Online Library), Database of Abstracts of Reviews of Effects (DARE) (via Centre for Reviews and Dissemination), Health Technology Assessment database (via the Centre for Reviews and Dissemination), Science Citation Index and Conference Proceedings [via the Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA)] and the PROSPERO International Prospective Register of Systematic Reviews (via the Centre for Reviews and Dissemination).

REVIEW METHODS

Eligible studies included those of people aged ≥ 5 years presenting with sore throat symptoms, studies comparing point-of-care testing with antibiotic-prescribing decisions, studies of test accuracy and studies of cost-effectiveness. Quality assessment of eligible studies was undertaken. Meta-analysis of sensitivity and specificity was carried out for tests with sufficient data. A decision tree model estimated costs and quality-adjusted life-years from an NHS and Personal Social Services perspective.

RESULTS

The searches identified 38 studies of clinical effectiveness and three studies of cost-effectiveness. Twenty-six full-text articles and abstracts reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard. In the population of interest (patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points), point estimates were 0.829 to 0.946 for sensitivity and 0.849 to 0.991 for specificity. There was considerable heterogeneity, even for studies using the same point-of-care test, suggesting that is unlikely that any single study will have accurately captured a test's true performance. There is some randomised controlled trial evidence to suggest that the use of rapid antigen detection tests may help to reduce antibiotic-prescribing rates. Sensitivity and specificity estimates for each test in each age group and care setting combination were obtained using meta-analyses where appropriate. Any apparent differences in test accuracy may not be attributable to the tests, and may have been caused by known differences in the studies, latent characteristics or chance. Fourteen of the 21 tests reviewed were included in the economic modelling, and these tests were not cost-effective within the current National Institute for Health and Care Excellence's cost-effectiveness thresholds. Uncertainties in the cost-effectiveness estimates included model parameter inputs and assumptions that increase the cost of testing, and the penalty for antibiotic overprescriptions.

LIMITATIONS

No information was identified for the elderly population or pharmacy setting. It was not possible to identify which test is the most accurate owing to the paucity of evidence.

CONCLUSIONS

The systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test. Further research is needed to understand the test accuracy of point-of-care tests in the proposed NHS pathway and in comparable settings and patient groups.

STUDY REGISTRATION

The protocol of the review is registered as PROSPERO CRD42018118653.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 31. See the NIHR Journals Library website for further project information.

Using point-of-care diagnostic testing for improved antibiotic prescription: an economic model

BACKGROUND

Antibiotics have been overprescribed to treat infectious diseases and have generated antimicrobial resistances that reduce their effectiveness. Following the rationale behind the new paradigm of personalized medicine, point-of-care diagnostic testing (POCT) has been proposed to improve the quality of antibiotic prescription with the aim of reducing antimicrobial resistances.

METHODS

In order to understand whether this recommendation is valid, we create a theoretical economic model to determine under which conditions the expected benefits of using POCT to guide antibiotic prescription are greater than for empiric prescription, where we define the expected benefits as the difference between the economic value of health and the costs of the treatment. We consider the interaction of a group of physicians who express differing levels of uncertainty when prescribing with a firm selling a diagnostic device, and analyse the firm's pricing policy and the physicians' prescribing decisions. We allow the physicians to internalize the external costs of antimicrobial resistances.

RESULTS

We find that the use of POCT reduces the number of antibiotic prescriptions. The reduction in antibiotic prescriptions is higher when physicians internalise the costs of antimicrobial resistances. Physicians with relatively high levels of uncertainty use POCT as they are uncertain about the right treatment for a large proportion of patients. Physicians with low levels of uncertainty prefer to prescribe empirically. The segmentation in the population of physicians regarding the uptake of POCT depends on the distribution of levels of uncertainty across physicians. For each test, the firm charges the marginal production costs of the inputs needed to administer the test, and makes its profit from the sales of the testing devices.

CONCLUSIONS

From a theoretical perspective, our findings corroborate the fact that POCT improve the quality of antibiotic prescription and reduce the number of prescriptions. Nevertheless, their use is not always recommended as empiric therapy may be preferred when uncertainty is low.

Economic evaluation of pharmacists prescribing for minor ailments in Ontario, Canada: a cost-minimization analysis

OBJECTIVES

The objective of this study was to use a decision-analytic model to examine the potential economic impact of establishing a remunerated programme for pharmacists prescribing for minor ailments (PPMA) in Ontario, Canada.

METHODS

A novel decision tool was developed to assess the economic impact of pharmacists prescribing for upper respiratory tract infections (URTIs), contact dermatitis (CD) and conjunctivitis by performing a cost-minimization analysis from a public payer perspective. Two prescribing strategies were compared: (1) PPMA, where patients may seek care from pharmacists or physicians, and (2) the usual care model (UCM), where all patients receive care from physicians. Two remuneration models for the PPMA strategy were also compared: (1) a prescription-detached scenario (PDS), where pharmacists were remunerated CAD$18.00 for each consultation, and (2) a Prescription-Attached Scenario (PAS), where pharmacists were only remunerated if a decision to prescribe was made.

KEY FINDINGS

At a service uptake rate of 38% for the PDS, the PPMA model led to savings of $7.51, $4.08 and $5.15 per patient for URTIs, CD and conjunctivitis, respectively. Per 30 000 patients, the PPMA model for these minor ailments was projected to lead to cumulative reductions in visits to the emergency department, family physician and walk-in clinics by 799, 3677 and 5090, respectively.

CONCLUSIONS

The results of the study strongly suggest that enabling community pharmacists to assess and prescribe for minor ailments could potentially lead to large savings for the government in Ontario, Canada. In 100% of the PAS scenarios simulated, pharmacists as prescribers led to cost savings.

Point-of-Care Testing for Pharyngitis in the Pharmacy

Pharyngitis (also known as sore throat) is a common, predominately viral, self-limiting condition which can be symptomatically managed without antibiotic treatment. Inappropriate antibiotic use for pharyngitis contributes to the development and spread of antibiotic resistance. However, a small proportion of sore throats caused by group A streptococcal (GAS) infection may benefit from the provision of antibiotics. Establishing the cause of infection is therefore an important step in effective antibiotic stewardship. Point-of-care (POC) tests, where results are available within minutes, can distinguish between viral and GAS pharyngitis and can therefore guide treatment in primary healthcare settings such as community pharmacies, which are often the first point of contact with the healthcare system. In this opinion article, the evidence for the use of POC testing in the community pharmacy has been discussed. Evidence suggests that pharmacy POC testing can promote appropriate antibiotic use and reduce the need for general practitioner consultations. Challenges to implementation include cost, training and 'who prescribes', with country and regional differences presenting a particular issue. Despite these challenges, POC testing for pharyngitis has become widely available in pharmacies in some countries and may represent a strategy to contain antibiotic resistance and contribute to antimicrobial stewardship.

Economic consequences of rheumatic heart disease: A scoping review

BACKGROUND

Rheumatic heart disease (RHD) remains endemic in less-resourced regions and countries and results in high medical and non-medical costs to households, health systems, and society. This scoping review maps out the available evidence on the economic impact of RHD and its antecedents and suggests future research priorities.

METHOD

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We identified articles through systematic electronic database search supplemented by expert knowledge of unpublished literature. Studies were included if they collected empirical RHD-related costing data as a primary or secondary objective and if the data were collected from 2000 onward. Main quantitative findings by intervention, costing perspective, and location were charted, and a standardized quality assessment tool was used to appraise included studies.

RESULTS

The index search identified 2519 electronic records and two grey-literature graduate theses. Six full texts were included in the review. Primary prevention costs were modest, while secondary and especially tertiary prevention were more costly. Most estimates were of health sector costs and for tertiary interventions. Only two studies described RHD-related costs in non-high-income countries. Most studies were of adequate methodological quality.

CONCLUSION

Research into the costs of RHD has mostly been done in wealthy countries. Costs from the household perspective, which are particularly important in countries with limited public healthcare finance, are lacking. To inform advocacy and guide implementation of the 2018 World Health Assembly resolution on RHD, high-quality, local cost estimates will be needed from a range of representative, RHD-endemic countries.