Department of Pharmacotherapy and Outcomes Science, Center for Pharmacy Practice Innovation, Virginia Commonwealth University School of Pharmacy, Richmond.
Broadstreet Health Economics and Outcomes Research, Vancouver, British Columbia, Canada.
JAMA Netw Open. 2023 Nov 1;6(11):e2341408. doi: 10.1001/jamanetworkopen.2023.41408.
Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear.
To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US.
DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023.
Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts.
Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years.
These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.
药师主导的干预措施可以显著改善血压（BP）控制。在美国大规模实施的药师处方干预措施的长期成本效益仍不清楚。
评估实施药师处方干预措施以改善美国血压控制的成本效益。
设计、设置和参与者：本经济评估包括基于在艾伯塔省高血压优化临床试验（或 RxACTION）（2009 年至 2013 年）中使用的药师处方干预措施的 5 州马尔可夫模型。在试验中，对照组患者接受了积极的干预，包括血压钱包卡、教育和常规护理。数据于 2023 年 1 月至 6 月进行分析。
心血管（CV）事件、终末期肾病事件、生命年、质量调整生命年（QALYs）、终生成本和终生增量成本效益比（ICER）。CV 风险使用 Framingham 风险方程计算。成本基于 1 级就诊的报销率、已发表文献中的药物成本以及来自全国调查和定价数据集的事件成本。生活质量使用已发表的 EQ-5D 效用值目录确定。进行了单因素敏感性分析，以评估替代报销价值、5 年较短的时间范围、BP 降低的替代假设以及干预 10 年后无获益的假设。该模型扩展到美国人口，以估计人口水平的成本和健康影响。
假设的人口统计学特征为平均（SD）年龄 64（12.5）岁，121（49%）为男性，基线 BP 平均（SD）为 150/84（13.9/11.5）mm Hg。在 30 年的时间范围内，与每 10000 名患者相比，药师处方干预措施可减少 2100 例 CV 疾病和 8 例肾脏疾病。该干预措施还与 0.34（2.5 百分位-97.5 百分位，0.23-0.45）个额外的生命年和 0.62（2.5 百分位-97.5 百分位，0.53-0.73）个额外的 QALYs 相关。由于药师处方干预措施导致 CV 事件减少，每人节省了 10162 美元（2.5 百分位-97.5 百分位，6636 美元-13581 美元）的成本，尽管就诊和药物调整的费用增加了。尽管成本增加，但 ICER 范围为 2093 美元至 24076 美元，干预措施在更保守的分析中仍具有益处。在人群水平上，50%的干预接受率与 1.137 万亿美元的成本节约相关，并且在 30 年内估计可以节省 3020 万生命年。
这些发现表明，改善血压控制的药师处方干预措施可能具有很高的经济价值。在美国实施药师处方干预措施的必要工具和资源已经具备；然而，报销限制仍然是一个障碍。
