Economic Evaluation of Pharmacist-led Medication Review in the Primary Health Care Centres in Chile

Research output: ThesisDoctoral Thesis

Abstract

Background: Cardiovascular diseases (CVD) pose a burden on healthcare systems. There is evidence that pharmacist-led medication review with follow-up (MRF) improves therapeutic goal achievement in CVD risk factors, such as hypertension, type 2 diabetes mellitus and dyslipidaemia. Objectives: To evaluate the economic impact of MRF added to Chilean primary care in CVD risk factors, by assessing the cost-effectiveness in older adults. Methodology: A systematic review was conducted to evaluate the economic evaluations of pharmacist-led MRF in outpatients with CVD risk factors. Recommendations were generated to design a cluster randomised controlled trial (cRCT). A cRCT was conducted in public primary care centres (clusters) in Chile to study the effect of MRF added to usual care compared to usual care alone. Older adults with five or more prescriptions, moderate or high CVD risk and enrolled in a primary care CVD prevention program were included. The intervention had three components: Pharmacists’ training, MRF, and a practice change facilitator. Patients were followed-up for a year. For the economic analysis, health-related quality of life (HRQoL) was measured and was used to estimate quality-adjusted life-years (QALYs). Costs were evaluated form the public third-party payer perspective and were measured as 2019 United States dollars (USD). A cost-effectiveness threshold of 16,207 USD was used. A trial-based cost-utility analysis was performed. Costs and QALYs were estimated through a multilevel model that accounted for clustering and covariates, while missing data was addressed using multiple imputation. Uncertainty was evaluated through a non-parametric bootstraping. As a second analysis, a state-transition microsimulation model was developed to extrapolate outcomes to a lifetime time horizon. Patient-level data was used to derive the model’s probabilities. Deterministic and probabilistic sensitivity analyses were performed. Results: Eleven studies were included in the systematic review. Eight found the intervention to be cost effective, while two found it to be dominant. Both, the trial-based and model analyses deemed the intervention as cost-effective. Incremental cost-effectiveness ratios of $434/QALY and $751/QALY respectively, were found. The trial-based analysis found increased dominant iterations when patients with more than nine medications were evaluated. In the model, a difference between groups of 5.9% in CVD mortality was observed. Sensitivity analyses showed either cost-effectiveness or dominance. Conclusion: International evidence shows that MRF was value for money in outpatient settings. An adapted MRF method was deemed as a cost-effective addition to primary care in Chile with low uncertainty. Formal implementation should be considered by policy makers.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • University of Technology Sydney
Supervisors/Advisors
  • Garcia-Cardenas, Victoria, Supervisor, External person
  • Benrimoj, Shalom, Supervisor, External person
  • Plaza-Plaza, Cristian, Supervisor, External person
Award date4 Sep 2020
Publication statusUnpublished - 2020
Externally publishedYes

Keywords

  • Medication review
  • Pharmacy
  • health services research
  • Cost-effectiveness

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