Cost Impact of a Pharmacist-Driven Medication Reconciliation Program during Transitions to Long-Term Care and Retirement Homes.

The current provincial funding model in Ontario, Canada, does not offer dedicated funding to drive medication reconciliation (MedRec) programs during transitions into long-term care and retirement homes. This economic analysis aimed to estimate potential cost savings attributed to hospitalizations averted and decreases in polypharmacy by a MedRec program from a healthcare payer perspective. From a pool of 6,678 pharmacist recommendations, a limited sample of recommendations targeting specific medication-related adverse events showed potential savings of $622.35 per patient from hospital admissions avoided and of $1,414.52 per patient per year from medication discontinuations. Pharmacist-driven MedRec, conducted virtually, delivers substantial healthcare savings.

Impact of collaborative clinician visits on postdischarge total cost of care in a polypharmacy population.

PURPOSE: To evaluate the impact of a collaborative intervention by pharmacists and primary care clinicians on total cost of care, including costs of inpatient readmissions, emergency department visits, and outpatient care, at 30, 60, and 180 days after hospital discharge in a population of patients at high risk for readmission due to polypharmacy. METHODS: A retrospective study of cost outcomes in a cohort of adult patients discharged from a single institution from July 1, 2013 to March 25, 2016, was conducted. All patients had at least 10 medications listed on their discharge list, including at least 1 drug frequently associated with adverse events leading to hospital readmission. About half of the cohort (n = 496) attended a postdischarge visit involving both a pharmacist and a primary care clinician (a physician, physician assistant, or licensed nurse practitioner); this was designated the pharmacist/clinician collaborative (PCC) group. The remainder of the cohort (n = 500) attended a visit without pharmacist involvement; this was designated as the usual care (UC) group. Costs were compared using a quantile regression to assess the potential heterogeneous impacts of the PCC intervention across different parts of the cost distribution. All outcomes were adjusted for differences in baseline characteristics. RESULTS: At 30 days post index discharge, there was a significant decrease in total costs in the 10th and 90th cost quantiles in the PCC cohort vs the UC cohort, without a statistically significant decrease in the 25th, 50th or 75th quantiles. The difference was significant in the 75th and 90th quantiles at 60 days and in the 25th, 50th, and 75th quantiles at 180 days. There was a nonsignificant cost reduction in all other quantiles. CONCLUSION: Medically complex patients had a significantly lower total cost of care in approximately half of the adjusted cost quantiles at 30, 60, and 180 days after hospital discharge when they had a PCC visit. PCC visits can improve patient clinical outcomes while improving cost metrics.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review.

PURPOSE: Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients. METHODS: A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology." RESULTS: Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis. CONCLUSION: Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Economic evaluations of pharmacist-led medication review in outpatients with hypertension, type 2 diabetes mellitus, and dyslipidaemia: a systematic review.

OBJECTIVES: To evaluate the health economics evidence based on randomized controlled trials of pharmacist-led medication review in pharmacotherapy managed cardiovascular disease risk factors, specifically, hypertension, type-2 diabetes mellitus and dyslipidaemia in ambulatory settings and to provide recommendations for future evaluations. METHODS: A systematic review was carried out according to the Cochrane Handbook for Systematic Reviews. PubMed (Medline), Scopus, Web of Science, National Health System Economic Evaluation Database (NHS EED), Cochrane Library, and Econlit were searched and screened by two independent authors. Incremental cost-effectiveness ratio was the main outcome. Risk of bias was assessed with the Effective Practice and Organisation of Care tool by the Cochrane Collaboration. Economic evaluation quality was assessed with the he Consensus Health Economic Criteria list (CHEC list). RESULTS: 5636 records were found, and 174 were retrieved for full-text review yielding 11 articles. Eight articles deemed the intervention as cost effective and two as dominant. Two cost-utility analyses were performed yielding ICERs of $612.7 and $59.8 per QALY. Four articles were considered to perform a high-quality economic evaluation and four had a low risk of bias. Future economic evaluations should consider cost-utility analysis, to describe usual care thoroughly, and use time horizons that capture the effect of cardiovascular disease prevention, a societal perspective and uncertainty analysis. CONCLUSION: Pharmacist-led medication review has proven to be cost effective in various studies in different settings. Policy decision makers are advised to undertake local economic evaluations reflecting the gaps observed in this systematic review and published literature. If this is not possible, a transferability assessment should be conducted.

Clinical and Economic Benefits of Pharmacist Involvement in a Community Hospital-Affiliated Patient-Centered Medical Home.

BACKGROUND: The primary goals of an accountable care organization (ACO) are to reduce health care spending and increase quality of care. Within an ACO, pharmacists have a unique opportunity to help carry out these goals within patient-centered medical homes (PCMHs). Pharmacy presence is increasing in these integrated care models, but the pharmacist's role and benefit is still being defined. OBJECTIVE: To exhibit the clinical and economic benefit of pharmacist involvement in ACOs and PCMHs as documented by clinical interventions (CIs) and drug cost reductions. METHODS: This is a retrospective quality improvement study. All interventions made by the pharmacist during the study period were documented using TAV Health. The interventions were then analyzed. Specific identified endpoints included the total number of documented interventions and number of CIs from each category, transition of care (TOC) medication reconciliations performed, discrepancies identified during TOC medication reconciliation, and cost savings generated from generic and therapeutic alternative use. CI categories were collaborative drug therapy management, medication therapy management (MTM), medication reconciliation, patient and provider education, and drug cost management. RESULTS: During the study period (October 2016-March 2017), a pharmacist was in clinic 8 hours per week. Sixty-three patients were included in the study. There were 283 CIs documented, with a majority of the interventions associated with MTM or cost management (94 and 88 CIs, respectively). There were 37 education CIs, 36 TOC medication reconciliations performed, and 28 collaborative drug therapy management CIs. From the 36 TOC medication reconciliations, 240 medication discrepancies were found, with a majority associated with medication omission. A cost savings of $118,409 was gained from generic and therapeutic alternative substitutions. CONCLUSIONS: Clinical benefit of pharmacy services was demonstrated through documented CIs. Pharmacists can have a dramatic and quantitative effect on reducing drug costs by recommending less expensive generic or therapeutic alternatives. Documenting CIs allows pharmacists to provide valuable evidence of avoided drug misadventures and identification of medication discrepancies. Such evidence supports an elevated quality of care. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. Study concept and design were contributed by Tate and Hopper, along with Bergeron. Tate collected and interpreted the data, as well wrote the manuscript, which was revised by all the authors.

Clinical and Financial Outcomes Evaluation of Multimodal Pharmacist Warfarin Management of a Statewide Urban and Rural Population.

PURPOSE: To evaluate the efficacy, safety, and indirect financial outcomes of pharmacist face-to-face warfarin management with telephone-based distance management utilizing local laboratories or patient self-testing (PST). METHODS: A retrospective analysis of a clinic population of 336 patients on established warfarin therapy distributed statewide in rural and urban settings over a 6-month period was conducted. Participants were stratified into face-to-face management, telephone-based management utilizing local laboratory testing, and telephone-based management utilizing PST. RESULTS: The primary outcome of international normalized ratio (INR) time in therapeutic range (TTR) for face-to-face management was significantly greater than distance management utilizing local laboratory testing (69.0% vs 60.5%, P = .0032). No difference was observed between face-to-face management and PST (69.0% vs 68.0%, P = .25). No significant difference in bleeding or thromboses was observed. Although increased clinician time was utilized during face-to-face encounters compared to telephone encounters (8.7-minute face-to-face, 5.5-minute local laboratory, and 5.4-minute PST), face-to-face encounters tended to be billable at lower levels, whereas telephone-based encounters were billable at higher levels. CONCLUSION: A multimodal approach to pharmacist warfarin management of a patient population distributed statewide in rural and urban locations is effective despite TTR differences associated with INR testing used in distance management. PST may improve warfarin treatment outcomes and adherence in distance management, particularly when the use of alternative oral anticoagulants is inappropriate. Although time and billing differences between face-to-face and distance management exist, clinical and safety outcomes remain acceptable despite encounter complexity and support reimbursement of pharmacist anticoagulation management in all settings.

The Feasibility and Impact of Prospective Medication Review in the Emergency Department.

OBJECTIVE: We evaluated the feasibility and impact of prospective medication review (PMR) in the emergency department (ED). METHODS: This was a retrospective cohort study of all nonadmitted ED patients who were prescribed medication orders by ED clinicians from September 2014 to September 2015 to determine the time intervals utilized during each step of the medication use process and quantify the number of interventions conducted by the pharmacist and cost avoidance accrued from the interventions. RESULTS: A total of 834 medication orders were included for evaluation. The median time for order verification, order verification to dispense, and dispense to administration were 3 minutes (interquartile range [IQR] = 1-7 minutes), 20 minutes (IQR = 7-45 minutes), and 10 minutes (IQR = 6-16 minutes). The median time interval for order verification was longer during the overnight pharmacy shift (median = 5 minutes, IQR = 2-9 minutes) compared to the day and evening shifts (median = 3 minutes, IQR = 1-6 minutes). A total of 563 interventions were recommended by the pharmacists and accepted by ED clinicians. These interventions equated to US$47 585 worth of cost avoidance. CONCLUSION: The PMR is a feasible process that resulted in safe and effective use of medications without causing delays to patient care.

The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit.

Medication errors may lead to adverse drug events (ADEs), which endangers patient safety and increases healthcare-related costs. The on-ward deployment of clinical pharmacists has been shown to reduce preventable ADEs, and save costs. The purpose of this study was to evaluate the ADEs prevention and cost-saving effects by clinical pharmacist deployment in a nephrology ward.This was a retrospective study, which compared the number of pharmacist interventions 1 year before and after a clinical pharmacist was deployed in a nephrology ward. The clinical pharmacist attended ward rounds, reviewed and revised all medication orders, and gave active recommendations of medication use. For intervention analysis, the numbers and types of the pharmacist's interventions in medication orders and the active recommendations were compared. For cost analysis, both estimated cost saving and avoidance were calculated and compared.The total numbers of pharmacist interventions in medication orders were 824 in 2012 (preintervention), and 1977 in 2013 (postintervention). The numbers of active recommendation were 40 in 2012, and 253 in 2013. The estimated cost savings in 2012 and 2013 were NT$52,072 and NT$144,138, respectively. The estimated cost avoidances of preventable ADEs in 2012 and 2013 were NT$3,383,700 and NT$7,342,200, respectively. The benefit/cost ratio increased from 4.29 to 9.36, and average admission days decreased by 2 days after the on-ward deployment of a clinical pharmacist.The number of pharmacist's interventions increased dramatically after her on-ward deployment. This service could reduce medication errors, preventable ADEs, and costs of both medications and potential ADEs.

Modeling the costs and benefits of temporary recommendations for poliovirus exporting countries to vaccinate international travelers.

Recognizing that infectious agents readily cross international borders, the International Health Regulations Emergency Committee issues Temporary Recommendations (TRs) that include vaccination of travelers from countries affected by public health emergencies, including serotype 1 wild polioviruses (WPV1s). This analysis estimates the costs and benefits of TRs implemented by countries with reported WPV1 during 2014-2016 while accounting for numerous uncertainties. We estimate the TR costs based on programmatic data and prior economic analyses and TR benefits by simulating potential WPV1 outbreaks in the absence of the TRs using the rate and extent of WPV1 importation outbreaks per reported WPV1 case during 2004-2013 and the number of reported WPV1 cases that occurred in countries with active TRs. The benefits of TRs outweigh the costs in 77% of model iterations, resulting in expected incremental net economic benefits of $210 million. Inclusion of indirect costs increases the costs by 13%, the expected savings from prevented outbreaks by 4%, and the expected incremental net benefits by 3%. Despite the considerable costs of implementing TRs, this study provides health and economic justification for these investments in the context of managing a disease in advanced stages of its global eradication.

Implementation of a reimbursed medication review program: Corporate and pharmacy level strategies.

BACKGROUND: In 2006, the Ontario drug plan greatly reduced community pharmacy reimbursement for generic drugs. In exchange, a fee-for-service medication review program was introduced to help patients better understand their medication therapy and ensure that medications were taken as prescribed. A qualitative study of community pharmacy implementation strategies was undertaken to inform a mixed methods evaluation of the program. PURPOSE: To describe strategies used by community pharmacies to implement a government-funded medication review service. METHODS: Key informant interviews were conducted with pharmacy corporate executives and managers, as well as independent pharmacy owners. All pharmacy corporations in the province were approached; owners were purposively sampled from the registry of the pharmacist licensing body to obtain diversity in pharmacy attributes; and pharmacy managers were identified through a mix of snowball and registry sampling. Thematic qualitative coding and analysis were applied to interview transcripts. RESULTS: 42 key informants, including 14 executives, 15 managers/franchisees, and 11 owners, participated. The most common implementation strategy was software adaptation to flag eligible patients and to document the service. Human resource management (task shifting to technicians and increasing the technician complement), staff training, and patient identification and recruitment processes were widely mentioned. Motivational strategies including service targets and financial incentives were less frequent but controversial. Strategies typically unfolded over time, and became multifaceted. Apart from the use of targets in chain pharmacies only, strategies were similar across pharmacy ownership types. DISCUSSION: Ontario community pharmacies appeared to have done little preplanning of implementation strategies. Strategies focused on service efficiency and quantity, rather than quality. Unlike other jurisdictions, many managers supported the use of targets as motivators, and very few reported feeling pressured. This detailed account of a range of implementation strategies may be of practical value to community pharmacy decision makers.

A Time and Motion Study of Pharmacists and Pharmacy Technicians Obtaining Admission Medication Histories.

Pharmacists' admission medication histories (AMHs) are known to reduce adverse drug events (ADEs). Pharmacist-supervised pharmacy technicians (PSPTs) have also been used in this role. Nonetheless, few studies estimate the costs of utilizing PSPTs to obtain AMHs. We used time and motion methodology to study the time and cost required for pharmacists and PSPTs to obtain AMHs for patients at high risk for ADEs. Pharmacists and PSPTs required 58.5 (95% confidence interval [CI], 46.9-70.1) and 79.4 (95% CI, 59.1-99.8) minutes per patient, respectively (P = 0.14). PSPT-obtained AMHs also required 26.0 (95% CI, 14.9-37.1) minutes of pharmacist supervision per patient. Based on 2015 US Bureau of Labor Statistics wage data, we estimated the cost of having pharmacists and PSPTs obtain AMHs to be $55.91 (95% CI, 44.9-67.0) and $45.00 (95% CI, 29.7-60.4), respectively, which included pharmacist supervisory cost, per patient (P = 0.32). Thus, we found no statistically significant difference in time or cost between the two provider types. Journal of Hospital Medicine 2017;12:180-183.

Pharmacy led medicine reconciliation at hospital: A systematic review of effects and costs.

BACKGROUND: Transition of patients care between settings presents an increased opportunity for errors and preventable morbidity. A number of studies outlined that pharmacy-led medicine reconciliation (MR) might facilitate safer information transfer and medication use. MR practice is not well standardized and often delivered in combination with other health care activities. The question regarding the effects and costs of pharmacy-led MR and the optimum MR practice is warranted of value. OBJECTIVES: To review the evidence for the effects and costs/cost-effectiveness of complete pharmacy-led MR in hospital settings. METHODS: A systematic review searching the following database was conducted up to the 13th December 2015; EMBASE & MEDLINE Ovid, CINAHL and the Cochrane library. Studies evaluating pharmacy-led MR performed fully from admission till discharges were included. Studies evaluated non-pharmacy-led MR at only one end of patient care or transfer was not included. Articles were screened and extracted independently by two investigators. Studies were divided into those in which: MR was the primary element of the intervention and labeled as "primarily MR" studies, or MR combined with non-MR care activities and labeled as "supplemented MR" studies. Quality assessment of studies was performed by independent reviewers using a pre-defined and validated tool. RESULTS: The literature search identified 4065 citations, of which 13 implemented complete MR. The lack of evidence precluded addressing the effects and costs of MR. CONCLUSIONS: The composite of optimum MR practice is not widely standardized and requires discussion among health professions and key organizations. Research focused on evaluating cost-effectiveness of pharmacy-led MR is lacking.

Cost-benefit of appointment-based medication synchronization in community pharmacies.

OBJECTIVES: To evaluate the cost-benefit of appointment-based medication synchronization (ABMS) offered in community pharmacies for patients taking chronic medications to prevent negative outcomes associated with hyperlipidemia, hypertension, and diabetes. STUDY DESIGN: Decision-tree analysis based on published literature and publicly available data. METHODS: Program benefits were based on linking published findings of improvements in medication adherence due to the implementation of an ABMS program to a claims-based study of disease-related medical costs associated with different levels of adherence. The direct cost of the program-increased medication utilization as a result of improved adherence-was calculated from publicly available prescription pricing data. Benefit-cost ratios were assessed from a payer perspective over a 1-year time frame. RESULTS: Additional medication expenditures due to improved adherence associated with ABMS enrollment were offset by lower disease-specific medical costs. Medical savings per additional dollar spent on medications ranged from approximately $1 to $37 depending on the medication and medication class considered. ABMS was most cost-beneficial for metformin and statins. Sensitivity analyses showed that cost-benefit was significantly impacted by medication costs and any service fees associated with ABMS. CONCLUSIONS: ABMS programs have been shown to increase medication adherence in patients taking chronic medications. These programs were shown to have a significant cost-benefit for healthcare payers by reducing medical utilization and costs. Payers should consider supporting the provision of these programs in community pharmacies.

An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs.

Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care.

Structured Pharmacist Review of Medication in Older Hospitalised Patients: A Cost-Effectiveness Analysis.

BACKGROUND: A recent cluster randomised controlled trial (RCT) conducted in an Irish hospital evaluating a structured pharmacist review of medication (SPRM), supported by computerised clinical decision support software (CDSS), demonstrated positive outcomes in terms of reduction of adverse drug reactions (ADR). OBJECTIVE: The aim of this study was to examine the cost effectiveness of pharmacists applying an SPRM in conjunction with CDSS to older hospitalised patients compared with usual pharmaceutical care. METHOD: Cost-effectiveness analysis alongside a cluster RCT. The trial was conducted in a tertiary hospital in the south of Ireland. Patients in the intervention arm (n = 361) received a multifactorial intervention consisting of medicines reconciliation, deployment of CDSS and generation of a pharmaceutical care plan. Patients in the control arm (n = 376) received usual care from the hospital pharmacy team. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of ADRs during an inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve (CEAC). RESULTS: On average, the intervention arm was the dominant strategy in terms of cost effectiveness. Compared with usual care (control), the intervention was associated with a decrease of €807 [95% confidence interval (CI) -3443 to 1829; p = 0.548) in mean healthcare cost, and a decrease in the mean number of ADR events per patient of -0.064 (95% CI -0.135 to 0.008; p = 0.081). The probability of the intervention being cost effective at respective threshold values of €0, €250, €500, €750, €1000 and €5000 was 0.707, 0.713, 0.716, 0.718, 0.722 and 0.784, respectively. CONCLUSIONS: Based on the evidence presented, SPRM/CDSS is likely to be determined to be cost effective compared with usual pharmaceutical care. However, neither incremental costs nor effects demonstrated a statistically significant difference, therefore the results of this single-site study should be interpreted with caution.

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.

OBJECTIVES: Medication discrepancies at the time of hospital discharge are common and can harm patients. Medication reconciliation by pharmacists has been shown to prevent such discrepancies and the adverse drug events (ADEs) that can result from them. Our objective was to estimate the economic value of nontargeted and targeted medication reconciliation conducted by pharmacists and pharmacy technicians at hospital discharge versus usual care. STUDY DESIGN: Discrete-event simulation model. METHODS: We developed a discrete-event simulation model to prospectively model the incidence of drug-related events from a hospital payer's perspective. The model assumptions were based on data published in the peer-reviewed literature. Incidences of medication discrepancies, preventable ADEs, emergency department visits, rehospitalizations, costs, and net benefit were estimated. RESULTS: The expected total cost of preventable ADEs was estimated to be $472 (95% credible interval [CI], $247-$778) per patient with usual care. Under the base-case assumption that medication reconciliation could reduce medication discrepancies by 52%, the cost of preventable ADEs could be reduced to $266 (95% CI, $150-$423), resulting in a net benefit of $206 (95% CI, $73-$373) per patient, after accounting for intervention costs. A medication reconciliation intervention that reduces medication discrepancies by at least 10% could cover the initial cost of intervention. Targeting medication reconciliation to high-risk individuals would achieve a higher net benefit than a nontargeted intervention only if the sensitivity and specificity of a screening tool were at least 90% and 70%, respectively. CONCLUSIONS: Our study suggests that implementing a pharmacist-led medication reconciliation intervention at hospital discharge could be cost saving compared with usual care.