Cost-effectiveness of a clinical medication review in vulnerable older patients at hospital discharge, a randomized controlled trial

Abstract

Background Drug-related problems (DRP) following hospital discharge may cause morbidity, mortality and hospital re-admissions. It is unclear whether a clinical medication review (CMR) and counseling at discharge is a cost-effective method to reduce DRP. Objective To assess the effect of a CMR on health care utilization and to investigate whether CMR is a cost-effective method to reduce DRP in older polypharmacy patients discharged from hospital. Setting 24 community pharmacies in the Netherlands. Method A cluster-randomized controlled trial with an economic evaluation. Community pharmacies were randomized to those providing a CMR, counseling and follow-up at discharge and those providing usual care. Main outcome measures Change in the number of DRP after 1 year of follow-up and costs of health care utilization during follow-up. In 216 patients the use of health care was prospectively assessed. Missing data on effects and costs were imputed using multiple imputation techniques. Bootstrapping techniques were used to estimate the uncertainty around the differences in costs and incremental cost-effectiveness ratios. Results CMR resulted in a small reduction of DRP. The proportion of patients readmitted to the hospital during 6 months of follow-up was significantly higher in the intervention group than in the control group (46.4 vs. 20.9%; p < 0.05). Health care costs were higher in the intervention group, although not statistically significant. The costs of reducing one DRP by a CMR amounted to €8270. Conclusion A CMR in vulnerable older patients at hospital discharge led to a small reduction in DRP. Because of a significantly higher use of health care and higher number of re-hospitalisations post CMR, the present study data indicate that performing the intervention in this patient population is not cost-effective.

Medication review interventions to reduce hospital readmissions in older people

“…Abbreviations: mdrev, medication review; mdrec, medication reconciliation; pedu, patient education/medication counseling; hpedu, health professional education; vm, use of validated methods; cds, use of Computerized Decision Support; ca, compliance aid; tc, transitional care compliance, (c) study-related involvement in medication management may have increased the complexity of care causing anxiety, confusion or dependence on health services, or (d) chance (type I error). 29,43 A strength of this study is the application of standard NMA as well as CNMA, in which we determined the effect of both the individual intervention components and the combinations of these components. Medication review is a very heterogeneous strategy and we investigated which particular combination of components of a medication review was most effective.…”

“…25,29,32,34 In the majority of the studies, at least half of the study population was female (n = 19, 76%). [25][26][27][28][29][31][32][33][35][36][37][38][39][40][43][44][45]48,49 In four studies (16%), 28,29,42,43 the intervention was community based within 2 weeks of discharge. The duration of follow-up of all studies varied from 4 weeks to 1 year.…”

“…Study size ranged from 22 to 4,049, over half (n = 21, 84%) of included studies had a study population ≥ 100. [25][26][27][28][29][30][31][32][33]35,[39][40][41][42][43][44][45][46][47][48][49] The mean/median number of regularly used medication was at least 6 and in most studies ranged between 6 and 10 (n = 18, 72%). [25][26][27][28][29][30]32,33,35,[37][38][39][40]43,44,[46][47][48] A summary of the characteristics of the medication review interventions is provided in Table S5.…”

“…In 76% of the studies, no information was reported at baseline on hospital (re)admissions in the preceding months (n = 19). 27,[29][30][31][32][33][34][35][36][37][38][39][42][43][44][45][46][47][48] Blinding of participants or personnel was not performed in the majority of studies. Blinded outcome assessment was performed in 17 studies (68%).…”

“…For the outcome "at least one all-cause hospital readmission at any time," the NMA included 24 studies (11,677 participants) [25][26][27][28][29][30][31][32][33][34][35][37][38][39][40][41][42][43][44][45][46][47][48][49] and 17 interventions ( Figure S4). All interventions consisting of multiple components were compared with usual care.…”