1. Clare A Mackie Centre for Partnerships in Medicines for Health Economic Evaluation of a RCT of a ‘Medication Review Clinic’ in Patients Receiving Repeat Prescriptions in a General Practice Setting A World Health Organisation (WHO) collaborating centre for Pharmaceutical Care and Curriculum Development

2. DURG 30th January 2003 Hypotheses: 1.‘ medication review by a person with a specialist knowledge of medicines will improve the quality of repeat prescribing compared to standard GP care’ 2.‘ medication review clinics within a general practice setting are cost-effective compared to the practices’ usual system of repeat prescribing’

3. DURG 30th January 2003 General Methods Study population: All patients  20 years, on  4 repeat medicines from six randomly selected GP practices in Glasgow Study design: randomised controlled trial Stratified: age, gender and practice Outcomes -Clinical: drug related problems (cDRPs) -Humanistic:satisfaction -Economic: cost effectiveness analysis

4. DURG 30th January 2003 Clinic Protocol 1. Patient profile compiled 2. Patient interviewed 3. Pharmaceutical Care plan 4. GP referral prepared for all - referral submitted for active patients only 5. Pharmacist implemented agreed plan

5. DURG 30th January 2003 Clinical Outcomes 1,677 (55%) patients participated with 1,603 (96%) completing the study 1,394 (83%) patients had  1DRP Active group 1,149 cDRPs –857 (75%) resolved at 9.6  2 months Control group 1,160 cDRPs –285 (25%) resolved at 9.7  2 months Significant reduction in cDRPs (  2 = 577 1df; p< 0.001); RR= 3.0 (2.7 to 3.4), NNT=2.

6. DURG 30th January 2003 Economic Evaluation: Methods Cost-effectiveness analysis Effectiveness- reduction in cDRPs Costs of intervention and changes in medicine costs were collected Clinic protocol kept close to standard care –only one clinic visit per patient –monitoring kept to a minimum –improved general applicability of the study therefore no adjustment required

7. DURG 30th January 2003 Methods continued Quantities reported separately from unit costs No discount rate was applied –relatively short 6-12 month follow-up Sensitivity analysis –pharmacy input 50% higher –impact on cDRPs 50% less Changes in productivity (indirect benefits) –prisms data compared for 18 month period before, during and after the intervention

8. DURG 30th January 2003 Results Cost of clinic =£19,600 (14,552- 24,648) Cost per intervention patient= £21(16-27) Cost per additional cDRP resolved= £34 (25-43) Changes in drug costs= +£17,946- £77,878 Savings in drug costs= £65 per patient or £104 per additional cDRP resolved Overall net gain of £44 (38-49) per patient or £71 (61-79) per additional cDRP resolved

9. DURG 30th January 2003 Sensitivity analysis Based on a 50% higher pharmacy input and 50% less impact on drug costs and cDRPs cost per patient  from £21 to £26 (19-33) cost per cDRP resolved £84 (61-107) savings on drug costs  to £33 per patient and £104 per additional cDRP resolved Overall the ‘medication review clinics’ would still be cost-effective before adjusting for changes in productivity

10. DURG 30th January 2003 Changes in productivity (indirect benefits) Prisms data collected for 18 month periods before, during and after intervention During intervention phase drug costs  by 1.3% compared to GGHB  of 13% –£489,000 indirect benefit Following intervention drug costs  by 12% compared to GGHB  of 11% –benefit not maintained beyond intervention

11. DURG 30th January 2003 Limitations Data come from a single clinical trial –study design high internal validity and large number of patients increases confidence in generalisability RCT often criticised highly motivated participants cannot extrapolate to ‘real life’ –GPs randomly selected, both groups of patients continued to receive standard care Pharmacists were highly motivated and experienced community pharmacists-not blinded during the patient interview

12. DURG 30th January 2003 Conclusions First, large RCT of ‘medication review clinics’ in which cost-effectiveness has been demonstrated in comparison to std GP care Cost per patient of £21 (16-27) was offset by savings in drug costs of £65 per patient Indirect benefit of ~ £500k during intervention Major implications for the NHS –improve the quality and cost-effectiveness of repeat prescribing in general practice