The European Journal of Health Economics

, Volume 18, Issue 9, pp 1069–1078 | Cite as

Cost analysis and cost-benefit analysis of a medication review with follow-up service in aged polypharmacy patients

  • Amaia Malet-Larrea
  • Estíbaliz Goyenechea
  • Miguel A. Gastelurrutia
  • Begoña Calvo
  • Victoria García-Cárdenas
  • Juan M. Cabases
  • Aránzazu Noain
  • Fernando Martínez-Martínez
  • Daniel Sabater-Hernández
  • Shalom I. Benrimoj
Original Paper



Drug related problems have a significant clinical and economic burden on patients and the healthcare system. Medication review with follow-up (MRF) is a professional pharmacy service aimed at improving patient’s health outcomes through an optimization of the medication.


To ascertain the economic impact of the MRF service provided in community pharmacies to aged polypharmacy patients comparing MRF with usual care, by undertaking a cost analysis and a cost-benefit analysis.


The economic evaluation was based on a cluster randomized controlled trial. Patients in the intervention group (IG) received the MRF service and the comparison group (CG) received usual care. The analysis was conducted from the national health system (NHS) perspective over 6 months. Direct medical costs were included and expressed in euros at 2014 prices. Health benefits were estimated by assigning a monetary value to the quality-adjusted life years. One-way deterministic sensitivity analysis was undertaken in order to analyse the uncertainty.


The analysis included 1403 patients (IG: n = 688 vs CG: n = 715). The cost analysis showed that the MRF saved 97 € per patient in 6 months. Extrapolating data to 1 year and assuming a fee for service of 22 € per patient-month, the estimated savings were 273 € per patient-year. The cost-benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained.


The MRF provided health benefits to patients and substantial cost savings to the NHS. Investment in this service would represent an efficient use of healthcare resources.


Pharmaceutical services Pharmacists Medication review Aged Cost and cost analysis Cost-benefit analysis 

JEL Classification




The authors would like to thank all of the pharmacists who participated in the conSIGUE Program.

We also acknowledge the financial support of the Spanish General Council of Official Colleges of Pharmacists and of CINFA Laboratory.

Amaia Malet-Larrea acknowledges the financial support of the Department of Education, Culture and Language Policy of the Basque Government through its Pre-doctoral Fellowship for Research Personnel in Training.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Chiatti, C., Bustacchini, S., Furneri, G., Mantovani, L., Cristian, M., Misuraca, C., et al.: The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review. Drug Saf. 35(Suppl 1), 73–87 (2012)CrossRefPubMedGoogle Scholar
  2. 2.
    Beer, C., Hyde, Z., Almeida, O.P., Norman, P., Hankey, G.J., Yeap, B.B., et al.: Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study. Br. J. Clin. Pharmacol. 71(4), 592–599 (2011)CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Chan, D.C., Chen, J.H., Kuo, H.K., We, C.J., Lu, I.S., Chiu, L.S., et al.: Drug-related problems (DRPs) identified from geriatric medication safety review clinics. Arch. Gerontol. Geriatr. 54(1), 168–174 (2012)CrossRefPubMedGoogle Scholar
  4. 4.
    Farrell, B., Szeto, W., Shamji, S.: Drug-related problems in the frail elderly. Can. Fam. Phys. 57(2), 168–169 (2011)Google Scholar
  5. 5.
    García, V., Marquina, I., Olabarri, A., Miranda, G., Rubiera, G., Baena, M.I.: Negative results associated with medication in the emergency department of a hospital. Farm. Hosp. 32(3), 157–162 (2008)CrossRefPubMedGoogle Scholar
  6. 6.
    Johnson, J.A., Bootman, J.L.: Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern. Med. 155(18), 1949–1956 (1995)CrossRefPubMedGoogle Scholar
  7. 7.
    Ernst, F.R., Grizzle, A.J.: Drug-related morbidity and mortality: updating the cost-of-illness model. J. Am. Pharm. Assoc. (Wash). 41(2), 192–199 (2001)CrossRefGoogle Scholar
  8. 8.
    Brummel, A., Lustig, A., Westrich, K., Evans, M.A., Plank, G.S., Penso, J., et al.: Best practices: improving patient outcomes and costs in an ACO through comprehensive medication therapy management. JMCP. 20(12), 1152–1158 (2014)CrossRefGoogle Scholar
  9. 9.
    Perez, A., Doloresco, F., Hoffman, J.M., Meek, P.D., Touchette, D.R., Vermeulen, L.C., et al.: ACCP: economic evaluations of clinical pharmacy services: 2001–2005. Pharmacotherapy. 29(1), 128 (2009)CrossRefPubMedGoogle Scholar
  10. 10.
    Schumock, G.T., Butler, M.G., Meek, P.D., Vermeulen, L.C., Arondekar, B.V., Bauman, J.L., et al.: Evidence of the economic benefit of clinical pharmacy services: 1996–2000. Pharmacotherapy. 23(1), 113–132 (2003)CrossRefPubMedGoogle Scholar
  11. 11.
    Schumock, G.T., Meek, P.D., Ploetz, P.A., Vermeulen, L.C.: Economic evaluations of clinical pharmacy services—1988–1995. Pharmacotherapy. 16(6), 1188–1208 (1996)PubMedGoogle Scholar
  12. 12.
    Touchette, D.R., Doloresco, F., Suda, K.J., Perez, A., Turner, S., Jalundhwala, Y., et al.: Economic evaluations of clinical pharmacy services: 2006–2010. Pharmacotherapy. 34(8), 771–793 (2014)CrossRefPubMedGoogle Scholar
  13. 13.
    Pharmaceutical Care Forum.: Expert panel. Consensus document. Spanish General Council of Official Colleges of Pharmacists, Madrid (2010) (ISBN: 9788469112434)Google Scholar
  14. 14.
    Martínez-Martínez, F., Gastelurrutia, M.A., Benrimoj, S.I., García-Cárdenas, V., Saez-Benito, L., Varas, R.: conSIGUE: clinical, economic and humanistic impact of the medication review with follow-up service in aged polypharmacy patients in Spanish community pharmacy. Spanish General Council of Official Colleges of Pharmacists, Madrid (2014). ISBN 978-84-87276-83-5Google Scholar
  15. 15.
    Jodar-Sanchez, F., Malet-Larrea, A., Martin, J.J., Garcia-Mochon, L., Lopez Del Amo, M.P., Martinez-Martinez, F., et al.: Cost-utility analysis of a medication review with follow-up service for older adults with polypharmacy in community pharmacies in Spain: the conSIGUE program. Pharmacoeconomics. 33(6), 599–610 (2015)CrossRefPubMedGoogle Scholar
  16. 16.
    Harvey, G., Loftus-Hills, A., Rycroft-Malone, J., Titchen, A., Kitson, A., McCormack, B., et al.: Getting evidence into practice: the role and function of facilitation. J. Adv. Nurs. 37(6), 577–588 (2002)CrossRefPubMedGoogle Scholar
  17. 17.
    Gastelurrutia, M.A., Faus, M.J., Fernandez-Llimos, F.: Providing patient care in community pharmacies in Spain. Ann. Pharmacother. 39(12), 2105–2110 (2005)CrossRefPubMedGoogle Scholar
  18. 18.
    BotPLUS web database.: Spanish General Council of Official Colleges of Pharmacists. Madrid. Available from: Accessed 15 November 2014
  19. 19.
    Order of 14 October 2005, which fixes public prices of health services provided by the Public Health System of Andalusia, BOJA 2010. Available from: Accessed June 12, 2014
  20. 20.
    Tariff book of public prices of the Public Health System of the Basque Country, 2014. Osakidetza. Available at: Accessed June 4, 2014
  21. 21.
    Decree 81/2009, 16 June, which fixes the public costs of health services of the Canarian Health Service. Available from: Accessed June 10, 2014
  22. 22.
    Ministry of Health, Social Services and Equalty, Spanish Government. [Weights and costs of DRGs. Ministry rule APv27.0.] (2010). Available from: Accessed July 5, 2014
  23. 23.
    Malet-Larrea, A., Goyenechea, E., Garcia-Cardenas, V., Calvo, B., Arteche, J.M., Aranegui, P., et al.: The impact of a medication review with follow-up service on hospital admissions in aged polypharmacy patients. Br. J. Clin. Pharmacol. 82(3), 831–838 (2016)CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Noain A, Garcia-Cardenas V, Gastelurrutia MA, Malet-Larrea A, Martínez-Martínez F, Sabater-Hernández D, Benrimoj SI. Cost analysis of a medication review with follow-up service in Spain. Int J Clin Pharm. Google Scholar
  25. 25.
    Casal-Sánchez, C., Losada-Campa, M.J.: Necessary times for the dispensation of electronic prescriptions in Galicia: necessities and processes. Farmacéuticos Comunitarios. 4(2), 52–62 (2012)Google Scholar
  26. 26.
    EuroQol Group. Spanish (Spain) version of EQ-5D-3L. Rotterdam (2014)Google Scholar
  27. 27.
    Ramos-Goñi, J.M., Rivero-Arias, O.: Eq5d: a command to calculate index values for the EQ-5D quality-of-life instrument. Stata J. 11(1), 120–125 (2011)Google Scholar
  28. 28.
    Robinson, A., Gyrd-Hansen, D., Bacon, P., Baker, R., Pennington, M., Donaldson, C., EuroVaQ Team: Estimating a WTP-based value of a QALY: the ‘chained’ approach. Soc. Sci. Med. 92, 92–104 (2013)CrossRefPubMedGoogle Scholar
  29. 29.
    Statistics Collegiate and Community Pharmacies 2012. Spanish General Council of Official Colleges of Pharmacists. Madrid. Available from: Accessed 7 Feb 2015
  30. 30.
    Abellán A, Esparza C.: A profile of the elderly in Spain, 2011. Basic statistical indicators. (Informes Portal Mayores no. 127). Madrid. Available from: Accessed 7 Feb 2015
  31. 31.
    Cosby, R.H., Howard, M., Kaczorowski, J., Willan, A.R., Sellors, J.W.: Randomizing patients by family practice: sample size estimation, intracluster correlation and data analysis. Fam. Pract. 20(1), 77–82 (2003)CrossRefPubMedGoogle Scholar
  32. 32.
    Community Pharmacy Medicines Management Project Evaluation Team: The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Fam. Pract. 24(2), 189–200 (2007)CrossRefGoogle Scholar
  33. 33.
    Elliott, R.A., Barber, N., Clifford, S., Horne, R., Hartley, E.: The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines. Pharm. World Sci. 30(1), 17–23 (2008)CrossRefPubMedGoogle Scholar
  34. 34.
    Benrimoj, S.I., Langford, J.H., Berry, G., Collins, D., Lauchlan, R., Stewart, K., et al.: Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance. Pharmacoeconomics. 18(5), 459–468 (2000)CrossRefPubMedGoogle Scholar
  35. 35.
    Cote, I., Gregoire, J.P., Moisan, J., Chabot, I., Lacroix, G.: A pharmacy-based health promotion programme in hypertension: cost-benefit analysis. Pharmacoeconomics. 21(6), 415–428 (2003)CrossRefPubMedGoogle Scholar
  36. 36.
    Gallagher, J., Byrne, S., Woods, N., Lynch, D., McCarthy, S.: Cost-outcome description of clinical pharmacist interventions in a university teaching hospital. BMC Health Serv. Res. 14, 177 (2014)CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Bunting, B.A., Cranor, C.W.: The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J. Am. Pharm. Assoc. 46(2), 133–147 (2006)CrossRefGoogle Scholar
  38. 38.
    Bunting, B.A., Smith, B.H., Sutherland, S.E.: The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J. Am. Pharm. Assoc. 48(1), 23–31 (2008)CrossRefGoogle Scholar
  39. 39.
    Saez-Benito, L., Fernandez-Llimos, F., Feletto, E., Gastelurrutia, M.A., Martinez-Martinez, F., Benrimoj, S.I.: Evidence of the clinical effectiveness of cognitive pharmaceutical services for aged patients. Age Ageing 42(4), 442–449 (2013)CrossRefPubMedGoogle Scholar
  40. 40.
    Beaucage, K., Lachance-Demers, H., Ngo, T.T., Vachon, C., Lamarre, D., Guevin, J.F., et al.: Telephone follow-up of patients receiving antibiotic prescriptions from community pharmacies. Am. J. Health Syst. Pharm. 63(6), 557–563 (2006)CrossRefPubMedGoogle Scholar
  41. 41.
    Sacristan, J.A., Oliva, J., Del Llano, J., Prieto, L., Pinto, J.L.: What is an efficient health technology in Spain? Gac. Sanit. 16(4), 334–343 (2002)CrossRefPubMedGoogle Scholar
  42. 42.
    Shiroiwa, T., Sung, Y.K., Fukuda, T., Lang, H.C., Bae, S.C., Tsutani, K.: International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness? Health Econ. 19(4), 422–437 (2010)CrossRefPubMedGoogle Scholar
  43. 43.
    Hirth, R.A., Chernew, M.E., Miller, E., Fendrick, A.M., Weissert, W.G.: Willingness to pay for a quality-adjusted life year: in search of a standard. Med. Decis. Mak. 20(3), 332–342 (2000)CrossRefGoogle Scholar
  44. 44.
    King Jr., J.T., Tsevat, J., Lave, J.R., Roberts, M.S.: Willingness to pay for a quality-adjusted life year: implications for societal health care resource allocation. Med. Decis. Mak. 25(6), 667–677 (2005)CrossRefGoogle Scholar
  45. 45.
    Pinto-Prades, J.L., Loomes, G., Brey, R.: Trying to estimate a monetary value for the QALY. J Health Econ. 28(3), 553–562 (2009)CrossRefPubMedGoogle Scholar
  46. 46.
    Shiroiwa, T., Igarashi, A., Fukuda, T., Ikeda, S.: WTP for a QALY and health states: more money for severer health states? Cost Eff. Resour. Alloc. 11, 22 (2013)CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Bernsten, C., Bjorkman, I., Caramona, M., Crealey, G., Frokjaer, B., Grundberger, E., et al.: Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries. Drugs Aging 18(1), 63–77 (2001)CrossRefPubMedGoogle Scholar
  48. 48.
    Cowper, P.A., Weinberger, M., Hanlon, J.T., Landsman, P.B., Samsa, G.P., Uttech, K.M., et al.: The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients. Pharmacotherapy. 18(2), 327–332 (1998)PubMedGoogle Scholar
  49. 49.
    Touchette DR, Masica AL, Dolor RJ, Schumock GT, Choi YK, Kim Y, et al.: Safety-focused medication therapy management: a randomized controlled trial. J. Am. Pharm. Assoc. (2003) 52(5), 603–12 (2012)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Amaia Malet-Larrea
    • 1
  • Estíbaliz Goyenechea
    • 2
  • Miguel A. Gastelurrutia
    • 3
  • Begoña Calvo
    • 1
  • Victoria García-Cárdenas
    • 4
  • Juan M. Cabases
    • 5
  • Aránzazu Noain
    • 3
  • Fernando Martínez-Martínez
    • 3
  • Daniel Sabater-Hernández
    • 3
    • 4
  • Shalom I. Benrimoj
    • 4
  1. 1.Pharmaceutical Technology Department, Faculty of PharmacyUniversity of the Basque CountryVitoriaSpain
  2. 2.Official Pharmacist Association of GuipúzcoaSan SebastiánSpain
  3. 3.Pharmaceutical Care Research Group, Faculty of PharmacyUniversity of GranadaGranadaSpain
  4. 4.Graduate School of HealthUniversity of Technology SydneyUltimoAustralia
  5. 5.Department of EconomicsPublic University of NavarraPamplonaSpain

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