O'Brien Gary L, O'Mahony Denis, Gillespie Paddy, Mulcahy Mark, Walshe Valerie, O'Connor Marie N, O'Sullivan David, Gallagher James, Byrne Stephen
Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy Building, University College Cork, Cork, Ireland.
School of Medicine, College of Medicine and Health Sciences, Brookfield Complex, University College Cork, Cork, Ireland.
Drugs Aging. 2018 Aug;35(8):751-762. doi: 10.1007/s40266-018-0564-0.
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.
最近在一家爱尔兰大学教学医院进行的一项随机对照试验评估了一种由医生实施的药物筛查工具，结果显示在减少药物不良反应发生率方面取得了积极成果。
本研究的目的是在早期随机对照试验的背景下，评估与常规医院护理相比，医生对老年住院患者应用这种筛查工具的成本效益。
我们在一项整群随机对照试验中，将成本效益分析与传统结局分析相结合。干预组（n = 360）的患者除接受常规医疗和药学护理外，还接受了多因素干预，包括药物重整、与患者的高级医疗团队沟通以及制定药学护理计划。对照组（n = 372）的患者仅接受常规医疗和药学护理。从医疗系统成本和住院期间药物不良反应的结局指标方面检查增量成本效益。使用成本效益可接受性曲线探讨分析中的不确定性。
平均而言，干预组成本更高，但也更有效。与常规护理（对照组）相比，干预使平均医疗成本非统计学显著增加877欧元（95%置信区间 - 1807欧元，3561欧元），且每位患者的药物不良反应事件平均数量统计学显著减少 - 0.164（95%置信区间 - 0.257， - 0.070）。避免每例药物不良反应的相关增量成本效益比为5358欧元。在阈值为0欧元、5000欧元和10000欧元时，干预具有成本效益的概率分别为0.236、0.455和0.680。
根据所提供的证据，与常规医院护理相比，这种由医生主导的干预不太可能具有成本效益。为了为该领域未来的医疗政策决策提供信息，需要对其他医疗专业人员通过结构化药物审查以及计算机化临床决策支持软件进行更多的经济分析。
