Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The conSIGUE Program

Abstract

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 €977.57 ± 1455.88 for the IG and €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 −€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.

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Acknowledgments

We thank all of the pharmacists who participated in the conSIGUE project. From Puerto Real University Hospital (Cádiz), we would like to thank Andrés Rabadán Asensio, Head of Public Health Department, and the three experts who evaluated the causes of hospital admissions: María José Pedrosa Martínez (specialist in Clinical Pharmacology), Julio González-Outón Velázquez (specialist in Preventive Medicine), and Emilio Jesús Alegre del Rey (specialist in Hospital Pharmacy).

The authors acknowledge health managers from the autonomous communities their collaboration.

Funding sources

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

Disclosures

The authors have no conflicts of interest.

Author contributions

FM-M and SIB acquired funding and coordinated the study. AM-L, FM-M, MAG-G, VG-C, DS-H, LS-B, and SIB designed the study and database. AM-L registered the data. FJ-S, JJM, LG-M, and MPLA analyzed the data and interpreted the results. All authors participated in the preparation of the manuscript. JJM is the guarantor for the overall content of the manuscript.

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Correspondence to José J. Martín.

Technical Appendix

Technical Appendix

Regression-Based Adjustment

  1. 1.

    This approach allows the estimation of differential total cost, as well as the prediction of adjusted total cost, while controlling for baseline prescribed medications. The equation is:

    $$ {\text{Cost}}_{i} = \beta_{0} + \beta_{1} \times T_{i} + \beta_{2} \times M_{i} $$

    where index i is the patient identifier (i = 1, 2, …, N); T i is the treatment arm dummy variable (0 = control; 1 = MRF service); and M i is the patient-specific baseline prescribed medication.

    The coefficient β 1 represents the adjusted differential cost after controlling for imbalance in the mean prescribed medication at baseline.

    Results:

    $$ \begin{aligned} {\text{Cost}}_{i} = \, 255.18 \, {-} \, 250.51 \times T_{i} + \, 125.41 \times M_{i} \hfill \\ R{\text{-squared}} = 0.013 \hfill \\ \end{aligned} $$
  2. 2.

    This approach allows the estimation of differential QALYs, as well as the prediction of adjusted QALYs, while controlling for baseline utility score. The equation is:

    $$ {\text{QALY}}_{i} = \, \beta_{0} + \, \beta_{1} \times \, T_{i} + \, \beta_{2} \times \, U_{i} $$

    where index i is the patient identifier (i = 1, 2, …, N); T i is the treatment arm dummy variable (0 = control; 1 = MRF service); and U i is the patient-specific baseline utility score.

    The coefficient β 1 represents the adjusted differential QALY after controlling for imbalance in the mean utility at baseline.

    Results:

    $$ \begin{aligned} {\text{QALY}}_{i} &= \, 0.077 \, + \, 0.016 \times T_{i} + \, 0.390 \times U_{i} \hfill \\ R{\text{-squared}}\;&= \;0.745 \hfill \\ \end{aligned} $$

    The regression-based approach not only generates an unbiased estimate of differential cost and QALYs between the arms of the study, but also increases the precision of the treatment effect estimate.

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Jódar-Sánchez, F., Malet-Larrea, A., Martín, J.J. 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, 599–610 (2015). https://doi.org/10.1007/s40273-015-0270-2

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Keywords

  • National Health Service
  • Prescribe Medication
  • Visual Analog Scale Score
  • Healthcare Resource
  • Community Pharmacy