Cost-Effectiveness Analysis of a Physician-Implemented Medication Screening Tool in Older Hospitalised Patients in Ireland
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A recent randomised controlled trial conducted in an Irish University teaching hospital that evaluated a physician-implemented medication screening tool, demonstrated positive outcomes in terms of a reduction in incident adverse drug reactions.
The present study objective was to evaluate the cost effectiveness of physicians applying this screening tool to older hospitalised patients compared with usual hospital care in the context of the earlier randomised controlled trial.
We used a cost-effectiveness analysis alongside a conventional outcome analysis in a cluster randomised controlled trial. Patients in the intervention arm (n = 360) received a multifactorial intervention consisting of medicines reconciliation, communication with patients’ senior medical team, and generation of a pharmaceutical care plan in addition to usual medical and pharmaceutical care. Control arm patients (n = 372) received usual medical and pharmaceutical care only. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of adverse drug reactions during inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve.
On average, the intervention arm was more costly but was also more effective. Compared with usual care (control), the intervention was associated with a non-statistically significant increase of €877 (95% confidence interval − €1807, €3561) in the mean healthcare cost, and a statistically significant decrease of − 0.164 (95% confidence interval − 0.257, − 0.070) in the mean number of adverse drug reaction events per patient. The associated incremental cost-effectiveness ratio per adverse drug reaction averted was €5358. The probability of the intervention being cost effective at threshold values of €0, €5000 and €10,000 was 0.236, 0.455 and 0.680, respectively.
Based on the evidence presented, this physician-led intervention is not likely to be cost effective compared with usual hospital care. To inform future healthcare policy decisions in this field, more economic analyses of structured medication reviews by other healthcare professionals and by computerised clinical decision support software need to be conducted.
The authors thank the patients and practitioners who participated in the trial.
GLO, SB, DO, PG, JG, VW and MM wrote the manuscript. GLO, PG and JG analysed the data. SB and DO designed the original research trial. MNO and DO recruited trial participants and gathered the original trial data.
Compliance with Ethical Standards
This research project was funded by the Health Research Board of Ireland (Grant HRA_HSR/2010/14) and the Irish Research Council (GOIPG/2016/635). The funders had no part in the design of the analysis, the collection, analysis and interpretation of the data, the writing of the report or the decision to submit the article for publication.
Conflict of interest
Stephen Byrne and Denis O’Mahony have part ownership in a patent “A Prescription Decision Support System” (based on STOPP/START prescribing rules); the patent was registered with the European Patent Office (Munich); Patent no. 11757950.8–1952. Stephen Byrne and Denis O’Mahony are also involved with two European Commission-funded grants that involve clinical trials in which there is computerised deployment of the STOPP/START criteria as part of an intervention designed to optimise pharmacotherapy in older adults. The first European Commission grant is called “Development and clinical trials of a new Software Engine for the Assessment and Optimization of drug and non-drug Therapy in Older peRsons [SENATOR]”, grant agreement 305930, awarded under the Seventh Framework Programme (FP7). The trial is registered with the US National Institutes of Health (NCT02097654). Denis O’Mahony is coordinator of the SENATOR project. The second European Commission-funded project is called “OPERAM: OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly”. OPERAM is funded under the Horizon 2020 programme (PHC 17-2014). The OPERAM trial is based on another software intervention called “Screening Tool to Reduce Inappropriate Prescribing”, which uses STOPP/START rules to assess the pharmacotherapy of older people. The trial is registered with the US National Institutes of Health (NCT02986425). Gary L. O’Brien, Paddy Gillespie, Mark Mulcahy, Valerie Walshe, Marie N. O’Connor, David O’Sullivan and James Gallagher have no conflicts of interest that are directly relevant to the content of this article.
The research ethics committee (institutional review board) of the local teaching hospitals network approved the trial protocol and the trial was registered with the US National Institutes of Health (NCT01467050).
Written consent was sought and obtained from all participating patients prior to enrolment in the study.
Journal of Economic Literature (JEL) Classification
This article is classified as I19 according to the JEL system.
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