Home and Community Care Digest

Home and Community Care Digest 7(3) September 2008

Private and Public Expenditures for Home Care: Substitute or Compliment?

Abstract

This English study determined the cost-effectiveness of home-based medication review by a pharmacist in the elderly compared with usual care in England. Cost-effectiveness analysis was conducted from the perspective of the NHS. The incremental cost per life year gained through the intervention was £33,541, while an incremental cost per Quality-adjusted life year was £54,454. Moreover, there was only a 25% probability of this form of medication review being cost-effective based on the commonly accepted UK threshold. These findings should raise a cautionary flag for other jurisdictions considering the use of pharmacists conducting in-home medication reviews for the elderly as a potential cost-saving measure.
Background: Many adverse drug events are predictable and potentially avoidable with medication review. In the UK, the new contractual framework for community included "Medicines Use Review" (MUR) as one of the advanced services that can be offered by accredited pharmacists. In a prior study, a home-based, face-to-face medication review by community pharmacists was found to increase hospital admissions by 30% and there was a non-significant difference in life-years gained and quality of life. In the current study the cost-effectiveness of home-based review in older people was compared with usual care from the NHS perspective.

Methods:
This economic evaluation was based on a large (n=872) randomized controlled trial, with a 6 month period follow-up. Patients 80 years and over, receiving two or more drugs, and due for discharge to their own home were randomized to receive either usual care or two home visits by a pharmacist to educate them about their drugs, remove out-of-date drugs, inform GPs of drug reactions or interactions and inform the local pharmacist if an adherence aid was needed. Intervention, hospital, ambulance and general practice costs were considered and measured in pound sterling for the year 2000. Outcomes included cost per life-year gained and cost per quality adjusted life year (QALY). Currently, a threshold of £25,000-35,000 per QALY is generally considered to be the maximum threshold at which interventions are deemed to be cost-effective in the UK

Results: Home-based medication review by a pharmacist did not reduce hospital admissions. The average costs per patient were £1695 and £1424 in the intervention and control groups, respectively. Patients in the intervention lived slightly longer (approximately 2 days) than the usual care group, but it was not statistically significant. The incremental cost per life year gained through the intervention was £33 541, while an incremental cost per QALY in the intervention was £54 454. Sensitivity analysis suggested there was a 25% probability that home-based medication review was cost effective using a threshold of £30 000 per QALY (the commonly accepted UK threshold).

Conclusions:
Despite the fact that some evidences suggested that medication review may improve patients' knowledge and adherence to drug regimens, this study found no reduction in hospital admission, no significant gain in patients' survival and no significant improvement in quality of life. In addition, the intervention was not deemed to be cost-effective. These findings should raise a cautionary flag for other jurisdictions considering the use of pharmacists conducting in-home medication reviews for the elderly as a potential cost-saving measure.

Reference: Pacini, M., Smith, R.D., Wilson, E.C.F., Holland, R.. Home-based Medication Review in Older People: Is It Cost effective? Pharmacoeconomics 2007; 25 (2): 171-180.

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