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A randomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients |
Sellors J, Kaczorowski J, Sellors C, Dolovich L, Woodward C, Willan A, Goeree R, Cosby R, Trim K, Sebaldt R, Howard M, Hardcastle L, Poston J |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study examined a pharmacist consultation programme for family physicians and their elderly patients. In this programme, the pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems.
Economic study type Cost-effectiveness analysis.
Study population Two populations were studied. One comprised family physicians, the other comprised elderly patients who were taking at least 5 medications daily.
Setting The setting was primary care. The economic analysis was conducted in Ontario, Canada.
Dates to which data relate The effectiveness and resource data were collected between August and November 1999. The price year was not reported.
Source of effectiveness data The effectiveness data were derived from a single prospective study.
Link between effectiveness and cost data The costing was carried out prospectively using the same sample of patients as that used in the effectiveness study.
Study sample Power calculations were reported. The study had a power of 80% to detect a 15% reduction in daily units of medication between the intervention and the control arms. A random sample of physicians (n=677) in each pharmacist's postal code area was generated and approached by telephone. Of the 163 physicians selected, 48 (69.6%) agreed to participate. The pairs of physicians were randomly allocated to the intervention group (n=24) or control group (n=24).
From these physicians, 1,279 eligible patients were randomly selected and were invited to participate. Of these patients, 889 (69.5%) consented to participate and 390 refused. After random allocation of the physicians, there were 431 seniors in the intervention group and 431 in the control group. The recruitment method was detailed elsewhere (see Other Publications of Related Interest).
Study design The study was a pair cluster, randomised controlled trial that was conducted in 24 sites in Ontario. The duration of follow-up was 5 months. Fifty-two patients in the intervention group and 49 in the control group did not complete the trial. At the end, 379 patients in the intervention group and 409 patients in the control group completed the trial.
Analysis of effectiveness The analysis of the clinical study was conducted on the basis of treatment completers only. The primary health outcomes used in the analysis were the reduction in the daily units of medication taken, the number of drug-related problems among the senior citizens in the intervention arm, and the proportion of recommendations implemented by the physicians. Quality of life was evaluated using the Medical Outcomes study 36-item Short Form (SF-36) quality of life survey, which was self-administered at the enrolment and exit interviews. The intervention and control groups had similar demographic and medical characteristics, and similar daily medication use. The mean age was 74 years in each group, and 64.3% (intervention group) versus 61.4% (control group) of the patients were women.
Effectiveness results After 5 months, the mean number of daily prescription and over-the-counter medication units was similar in the intervention (12.4) and control (12.2) groups, (p=0.50). The number of medications taken per day was also similar, 8.0 versus 7.9, (p=0.87).
The pharmacists identified at least one drug-related problem in 79.8% of the patients in the intervention group. The mean number of drug-related problems was 2.5 per patient (range: 0 - 9).
The physicians reported that they intended to implement 76.6% of the pharmacists' recommendations. They had succeeded in fully implementing 46.3% of these recommendations and partially implementing 9.3%. Implementation for 16.7% of the recommendations was unsuccessful.
Reductions in the mean scores for health-related quality of life were observed in both groups for most of the sub-scales of the SF-36 quality of life survey from baseline to study exit, except for physical functioning in the control group (54.2 versus 55.0). There were no significant differences between the groups.
Clinical conclusions The intervention did not have a significant effect on patient outcomes. However, the physicians were receptive to recommendations to resolve drug-related problems.
Measure of benefits used in the economic analysis The authors did not develop a summary benefit measure. A cost-consequences analysis was therefore performed.
Direct costs The perspective adopted in the study was not reported. The direct costs were for hospital admissions, drug-related hospital stays, physician and clinic visits, laboratory tests/imaging procedures, surgical procedures, emergency/urgent care visits and ambulance use, and other health care services/visits to health professionals. Ontario drug benefit programme prices were used for the drug costs. All other prices were obtained from a commercial drug wholesaler database or from local pharmacies. The average daily costs were calculated for all medications. The quantities were estimated from the clinical trial. The cost of hospital stays and other health services costs were obtained from an area hospital that was participating in the Ontario Case Costing Project (www.occp.com). The price year was not reported. The costs and the quantities were reported separately.
Statistical analysis of costs A statistical analysis of the costs was conducted, using the asymptotic chi-squared test.
Indirect Costs No indirect costs were included in the analysis.
Sensitivity analysis No sensitivity analysis was conducted.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results There was no significant difference between the intervention and control groups in any dimension of resource use.
The mean cost of drug-related hospital stays was $142.51 in the intervention group versus $248.54 in the control group, (p=0.08).
The mean cost of health care resources per elderly patient was $1,894.10 in the intervention group and $1,644.69 in the control group, (p=0.83).
When including the cost of the pharmacist intervention and only drug-related hospital stays, the mean cost of health care resources per elderly patient was $1,299.37 in the control group and $1,281.27 in the intervention group, (p=0.45).
Synthesis of costs and benefits Authors' conclusions Although the pharmacist intervention did not have statistically significant effects on the number and cost of medications, health care use and cost, or health-related quality of life, the physicians did act on the majority of recommendations made by the pharmacists.
CRD COMMENTARY - Selection of comparators A justification was given for the comparator used, which represented usual care in the authors' setting. You should consider whether this is a widely used technology in your own setting.
Validity of estimate of measure of effectiveness The estimate of effectiveness should have been internally valid given the use of a randomised controlled trial. Power calculations were reported. The study sample was representative of the study population. The patient groups were shown to be comparable at analysis, suggesting a low risk of confounding factors. However, the authors acknowledged that the length of follow-up was too brief to capture the impacts of improved drug therapy, for example, in terms of mortality rate. Appropriate statistical analyses were performed to ensure the accuracy of the comparison.
Validity of estimate of measure of benefit The authors did not develop a summary benefit measure and a cost-consequences analysis was therefore performed.
Validity of estimate of costs The perspective of the study was not reported, but it is likely to have been that of the health care system. It appears that all the categories of cost relevant to this perspective have been included in the analysis. The costs and the quantities were reported separately. There was no statistical analysis of the quantities. A statistical analysis of the differences in costs was conducted. Discounting was unnecessary since all the costs were incurred in less than one year.
Other issues The generalisability of the results was partially discussed and adequate comparisons were made with studies dealing with the same topic. The authors highlighted the limitations of their study. They do not appear to have reported their results selectively.
Implications of the study The authors suggested that, although no improvements in patient outcomes were found, this study has demonstrated the feasibility and acceptability of a collaborative relationship between family physicians and local, specially trained pharmacists.
Source of funding Funding provided by the Health Transition Fund, Health Canada.
Bibliographic details Sellors J, Kaczorowski J, Sellors C, Dolovich L, Woodward C, Willan A, Goeree R, Cosby R, Trim K, Sebaldt R, Howard M, Hardcastle L, Poston J. A randomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients. CMAJ: Canadian Medical Association Journal 2003; 169(1): 17-22 Other publications of related interest Sellors J, Cosby R, Trim K, et al. Recruiting family physicians and patients for a clinical trial: lessons learned. Family Practice 2002;19:99-104.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Attitude of Health Personnel; Community Pharmacy Services /organization & Cooperative Behavior; Drug Costs /statistics & Female; Health Care Costs /statistics & Health Services Research; Humans; Interprofessional Relations; Male; Ontario; Outcome and Process Assessment (Health Care) /organization & Patient Care Team; Pharmacists /organization & Physicians, Family /organization & Primary Health Care /organization & Program Evaluation; Referral and Consultation /organization & administration; administration; administration; administration; administration /psychology; administration /psychology; numerical data; numerical data AccessionNumber 22003008192 Date bibliographic record published 29/02/2004 Date abstract record published 29/02/2004 |
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