Home-Based Medication Review in Older People: Is it Cost Effective?
Richard D. Smith
Edward C.F. Wilson
Background: Medication review by pharmacists is increasingly being implemented in the primary care setting and has been incorporated into the new pharmacy contract in the UK. This study aims to determine the cost effectiveness of home-based medication review in older people. Methods: This economic evaluation was based on a randomised controlled trial (the HOMER [HOME-based medication Review] trial). Patients aged >80 years (n_=_872) were recruited if admitted as an emergency to an acute or community hospital in Norfolk or Suffolk (any cause), returning to their own home or warden-controlled accommodation, and taking two or more drugs daily on discharge. Patients randomised to the intervention group received two home visits by a pharmacist within 2 and 8 weeks of discharge to educate patients and carers about their drugs, remove out-of-date drugs, inform GPs of drug reactions or interactions and inform the local pharmacist if an adherence aid was needed. The control arm received usual care. Economic evaluation was performed from the UK NHS perspective, with follow-up for 6 months and cost data from 2000. Resource use data were collected from hospital episode statistics and from a sample of GP records of trial participants. Intervention, hospital, ambulance and general practice costs were considered to determine average costs and incremental cost-effectiveness ratios. Use of the EQ-5D questionnaire permitted outcomes to be expressed as QALYs. Probabilistic sensitivity analysis was employed to calculate cost-effectiveness acceptability curves. Results: Mortality and admission data were available for 829 of 855 patients included in the study (415 intervention and 414 control patients). Of those patients randomised to the intervention group, 358 had a medication review at a total intervention cost of Lstg 51_622 (or Lstg 124 per randomised patient). The intervention did not reduce hospital admissions. The average cost per intervention group patient was Lstg 1695 compared with Lstg 1424 for control patients. The incremental cost per life year gained through the intervention was Lstg 33_541. The incremental cost per QALY gained in the intervention was Lstg 54_454. Sensitivity analysis suggested a 25% probability that home-based medication review is cost effective using a threshold of Lstg 30_000 per QALY. Conclusion: The current policy imperative for implementing medicines review needs to be reconsidered in the light of the findings of this study: a small, non significant gain in quality of life, no reduction in hospital admissions and a low probability of cost effectiveness.
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