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A Review of the Methodological Challenges in Assessing the Cost Effectiveness of Pharmacist Interventions

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Abstract

Pharmacists’ roles are shifting away from medicines supply and the provision of patient education involving acute medications towards consultation-type services for chronic medications. Determining the cost effectiveness of pharmacist interventions has been complicated by methodological challenges. A critique of 31 economic evaluations carried out alongside comparative studies of pharmacist interventions published between 2003 and 2013 (12 from the UK, six from the USA) found a range of disease-specific and cross-therapeutic interventions targeting both patients and prescribers in a range of settings evaluated through a variety of study designs. Only ten were full economic evaluations, five of which were based on randomized controlled trials (RCTs). The intervention was usually quite well described, but the comparator was not always clearly described, and some interventions are very context specific due to the variability in pharmacist services available in different countries and practice settings. Complex multidirectional aims of most pharmacist interventions have led to many process, intermediate and longer-term outcomes being included in any one study. Quality of resource use and cost data varied. Most incremental cost-effectiveness ratios (ICERs) were generated from process indicators such as errors and adherence, with only four studies reporting cost per quality-adjusted life-year (QALY). Very few studies examined the effect of uncertainty, and methods used were not very clear in some cases. The principal finding from our critique is that poor RCT study design or analysis precludes many studies from finding pharmacist interventions effective or cost effective. We conclude with a set of recommendations for future study design.

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Acknowledgments

The authors would like to thank the referees for the time they spent reviewing our paper, and for comments that have helped to improve the final version.

Competing interests

The authors (Rachel A Elliott, Koen Putman, James Davies, Lieven Annemans) declare that they have no competing interests.

Author contributions

Rachel A Elliott designed and led the critique, double checked the individual study appraisals and led drafting of the manuscript.

Koen Putman led the extraction and review of the individual studies, structuring the critique and was involved in the drafting of the manuscript.

James Davies contributed to the critique, provided pharmacy profession expertise and was involved in the drafting of the manuscript.

Lieven Annemans contributed to the critique, provided methodological expertise and was involved in the drafting of the manuscript.

Rachel A Elliott will act as overall guarantor. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

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Authors and Affiliations

  1. Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, East Drive, Nottingham, NG7 2RD, UK

    Rachel A. Elliott

  2. Interuniversity Centre for Health Economics Research, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium

    Koen Putman

  3. UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK

    James Davies

  4. Vrije Universiteit Brussel (VUB), Ghent University, Brussels, Belgium

    Lieven Annemans

  5. Ghent University Hospital, Block A, 2nd fl., De Pintelaan 185, 9000, Ghent, Belgium

    Lieven Annemans

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  1. Rachel A. Elliott
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Correspondence to Rachel A. Elliott.

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Elliott, R.A., Putman, K., Davies, J. et al. A Review of the Methodological Challenges in Assessing the Cost Effectiveness of Pharmacist Interventions. PharmacoEconomics 32, 1185–1199 (2014). https://doi.org/10.1007/s40273-014-0197-z

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