Pharmacist-led management of chronic pain in primary care: costs and benefits in a pilot randomised controlled trial

Abstract

ObjectivesTo explore differences in mean costs (from a UK National Health Service perspective) and effects of pharmacist-led management of chronic pain in primary care evaluated in a pilot randomised controlled trial (RCT), and to estimate optimal sample size for a definitive RCT.DesignRegression analysis of costs and effects, using intention-to-treat and expected value of sample information analysis (EVSI).SettingSix general practices: Grampian (3); East Anglia (3).Participants125 patients with complete resource use and short form-six-dimension questionnaire (SF-6D) data at baseline, 3 months and 6 months.InterventionsPatients were randomised to either pharmacist medication review with face-to-face pharmacist prescribing or pharmacist medication review with feedback to general practitioner or treatment as usual (TAU).Main outcome measuresDifferences in mean total costs and effects measured as quality-adjusted life years (QALYs) at 6 months and EVSI for sample size calculation.ResultsUnadjusted total mean costs per patient were £452 for prescribing (SD: £466), £570 for review (SD: £527) and £668 for TAU (SD: £1333). After controlling for baseline costs, the adjusted mean cost differences per patient relative to TAU were £77 for prescribing (95% CI −82 to 237) and £54 for review (95% CI −103 to 212). Unadjusted mean QALYs were 0.3213 for prescribing (SD: 0.0659), 0.3161 for review (SD: 0.0684) and 0.3079 for TAU (SD: 0.0606). Relative to TAU, the adjusted mean differences were 0.0069 for prescribing (95% CI −0.0091 to 0.0229) and 0.0097 for review (95% CI −0.0054 to 0.0248). The EVSI suggested the optimal future trial size was between 460 and 690, and between 540 and 780 patients per arm using a threshold of £30 000 and £20 000 per QALY gained, respectively.ConclusionsCompared with TAU, pharmacist-led interventions for chronic pain appear more costly and provide similar QALYs. However, these estimates are imprecise due to the small size of the pilot trial. The EVSI indicates that a larger trial is necessary to obtain more precise estimates of differences in mean effects and costs between treatment groups.Trial registration numberISRCTN06131530.

Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials

“…Reviewing by title and abstract excluded 158 studies that were not RCTs. The full texts of the remaining 3 trials [ 26 – 28 ] were examined in detail and evaluated as meeting the inclusion criteria. A further article [ 29 ] retrieved when examining the reference lists of retrieved studies was included as it presented additional data to an included RCT.…”

“…A further article [ 29 ] retrieved when examining the reference lists of retrieved studies was included as it presented additional data to an included RCT. The data from the two articles were considered as one pilot trial (The PIPPC pilot trial) [ 26 , 29 ]. Therefore, 3 trials (2 definitive trials and 1 pilot trial) were included ( Fig 3 ).…”

“…Therefore, 3 trials (2 definitive trials and 1 pilot trial) were included ( Fig 3 ). All included trials investigated clinical effectiveness (n = 3) [ 27 – 29 ]; 1 trial investigated cost effectiveness [ 26 ]. Fig 3 presents the number of studies at each stage of the selection process.…”

Self‐medication in pain management: The state of the art of pharmacists’ role for optimal Over‐The‐Counter analgesic use

“…A pilot randomized study performed in the United Kingdom in patients receiving regular prescribed medication for pain (at least two acute and/or one repeated prescriptions within the four previous months) showed that pharmacist‐led medication based on medication review and feedback to the GP was associated with a cost increase of £54 per patient when compared with GP‐led treatment as usual. The difference reached £77 per patient when pharmacist intervention included prescribing instead of feedback to GP (Neilson et al, ). The benefits for patients assessed as quality‐adjusted life years (QALYs) at 6 months were similar in the three arms.…”

Clinical pharmacists in primary care: a safe solution to the workforce crisis?

“…However, it may be necessary to implement changes at scale in order to see cost savings; one pilot study of pharmacist-led chronic pain management resulted in increased costs compared with usual care. 21 …”