Economic evaluation of a collaborative model of pharmaceutical care in an Irish hospital: cost-utility analysis.

Background: A complex, collaborative pharmaceutical care intervention including medication review and reconciliation demonstrated a statistically significant reduction in the prevalence of discharge medication error and improved quality of prescribing for hospitalised adults.  This study sought to assess the cost-effectiveness of this intervention. Methods: A cost-utility analysis was undertaken using a decision-analytic framework. The evaluation was undertaken from the Health Service Executive's perspective, the payer for primary and secondary care settings. Direct costs associated with managing hypothetical harm consequent to intercepted discharge medication error and consequences in terms of quality-adjusted life years loss were key input parameters. Analysis was structured within a decision tree model in Microsoft Excel® populated with consequences as utilities, estimated costs using macro- and micro-costing approaches, and event probabilities generated from the original study. Incremental analysis, one-way and probabilistic sensitivity analyses were performed. Results: The results of analysis for the base-care demonstrated that the intervention dominated standard care with an incremental cost-effectiveness ratio of -€36,537.24/quality-adjusted life year, indicating that the intervention is less costly and more effective. The one-way and probabilistic sensitivity analyses both demonstrated that the intervention dominated standard care. The model was relatively robust to variation in input parameters through one-way sensitivity analysis. The cost of discharge medication error and effect parameters relating to standard care were most sensitive to change. Discussion: The analysis demonstrated the cost-effectiveness of a complex pharmaceutical intervention which will support decision-making regarding implementation. This is the first cost-utility analysis of a complex, collaborative pharmaceutical care intervention, adding to the scant evidence-base in the field.

Medication-Related Outcomes and Health Equity: Evidence for Pharmaceutical Care.

Marginalised people experience diminished access to pharmaceutical care and worse medication-related outcomes than the general population. Health equity is a global priority. This article explores the key evidence of health inequity and medication use, structures the causes and contributory factors and suggests opportunities that can be taken to advance the pharmaceutical care agenda so as to achieve health equity. The causes of, and contributors to, this inequity are multi-fold, with patient- and person-related factors being the most commonly reported. Limited evidence is available to identify risk factors related to other aspects of a personal medication use system, such as technology, tasks, tools and the internal and the external environments. Multiple opportunities exist to enhance equity in medication-related outcomes through pharmaceutical care research and practice. To optimise the effects and the sustainable implementation of these opportunities, it is important to (1) ensure the meaningful inclusion and engagement of members of marginalised groups, (2) use a person-centred approach and (3) apply a systems-based approach to address all of the necessary components of a system that interact and form a network as work processes that produce system outcomes.

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study.

OBJECTIVES: Assessing the cost-effectiveness of complex pharmaceutical care interventions and medication error outcomes is hindered by lack of available data on actual outcomes consequent to errors that were intercepted for patient safety reasons. Expert judgement is an approach to acquire data regarding unknown parameters in an economic model which are otherwise insufficient or not possible to obtain. The aim of this paper is to describe a method to approach this problem using findings from a single intervention study and to calculate the potential costs and consequences associated with discharge medication error. METHODS: Using data from a previous intervention study, the hypothetical consequences of medication error(s) at hospital discharge, in terms of diagnosis, healthcare resource utilisation and impact on health-related quality of life, were identified by expert judgement of anonymised cases. Primary healthcare utilisation costs were derived from published tariffs, inpatient costs were derived by simulation in the hospital discharge activity database test environment and the difference between adjudicated baseline and posterror health state was expressed as quality-adjusted life year (QALY) decrement. RESULTS: Four experts provided judgement on 81 cases. Of these, 75 were judged to have potential clinical consequences. Between 56 and 69 of the 81 cases were variably judged to require remedial healthcare utilisation. The mean calculated cost per case (representing an individual patient), based on all 81 cases, was €1009.58, 95% CI 726.64 to 1585.67. The mean QALY loss was 0.03 (95% CI 0.01 to 0.05). CONCLUSION: An expert judgement process proved feasible and useful to estimate financial cost and QALY loss associated with hospital discharge medication error. These estimates will be employed in model-based economic evaluation. This method could be transferred to other prospective observational patient safety research which seeks to assess value for money of complex interventions.