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Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients.

ABSTRACT: BACKGROUND:Current evidence to support cost effectiveness of doctor- pharmacist collaborative prescribing is limited. Our aim was to evaluate inpatient prescribing of venous thromboembolism (VTE) prophylaxis by a pharmacist in an elective surgery pre-admission clinic against usual care, to measure any benefits in cost to the healthcare system and quality adjusted life years (QALYs) of patients. METHOD:A decision tree model was developed to assess cost effectiveness of pharmacist prescribing compared with usual care for VTE prophylaxis in high risk surgical patients. Data from the literature was used to inform decision-tree probabilities, utility, and cost outcomes. In the intervention arm, a pharmacist prescribed patient's regular medications, documented a VTE risk assessment and prescribed VTE prophylaxis. In the usual care arm, resident medical officers were responsible for prescribing regular medications, and for risk assessment and prescribing of VTE prophylaxis. The base scenario assessed the cost effectiveness of a pre-existing pre-admission clinic pharmacy service that takes on a collaborative prescribing role. The alternative scenario assessed the benefits of introducing a pre-admission clinic pharmacy service where previously there had not been one. Probabilistic sensitivity analysis was conducted to explore uncertainty in the model. RESULTS:In both the base-case scenario and the alternative scenario pharmacist prescribing resulted in an increase in the proportion of patients adequately treated and a decrease in the incidence of VTE resulting in cost savings and improvement in quality of life. The cost savings were $31 (95% CI: -$97, $160) per patient in the base scenario and $12 (95% CI: -$131, $155) per patient in the alternative scenario. In both scenarios the pharmacist-doctor prescribing resulted in an increase in QALYs of 0.02 (95% CI: -0.01, 0.005) per patient. The probability of being cost effective at a willingness to pay off $40,000 was 95% in the base scenario and 94% in the alternative scenario. CONCLUSION:Delegation of the prescribing of VTE prophylaxis for high risk surgical patients to a pharmacist prescriber in PAC, as part of a designated scope of practice, would result in fewer cases of VTE and associated lower costs to the healthcare system and increased QALYs gained by patients. TRIAL REGISTRATION:Pre admission clinic study registered with ANZCTR-ACTR Number ACTRN12609000426280 .

SUBMITTER: Hale A

PROVIDER: S-EPMC6167876 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients.

Hale Andrew A Merlo Greg G Nissen Lisa L Coombes Ian I Graves Nicholas N

BMC health services research 20181001 1

<h4>Background</h4>Current evidence to support cost effectiveness of doctor- pharmacist collaborative prescribing is limited. Our aim was to evaluate inpatient prescribing of venous thromboembolism (VTE) prophylaxis by a pharmacist in an elective surgery pre-admission clinic against usual care, to measure any benefits in cost to the healthcare system and quality adjusted life years (QALYs) of patients.<h4>Method</h4>A decision tree model was developed to assess cost effectiveness of pharmacist p ...[more]

PMID: 30285744

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Project description:Background: Direct oral anticoagulants (DOACs) are increasingly prescribed for the treatment of venous thromboembolism (VTE). However, little is known regarding pharmacists' practice patterns and preferences in clinical areas of contention, such as initiation dosing, obesity, and renal impairment. Objective: To determine pharmacist trends in practice regarding DOACs for the treatment of VTE overall and within areas of clinical controversy. Methods: An electronic survey was distributed to pharmacists in the United States through national and state pharmacy organizations. Responses were collected for 30 days. Results: One hundred fifty-three complete responses were submitted. The majority of pharmacists preferred apixaban (90.2%) for the oral treatment of venous thromboembolism. When initiating apixaban or rivaroxaban for a new VTE, 76% and 64% of pharmacists surveyed, respectively, state the duration of the initiation dose phases are reduced if the patient received parenteral anticoagulation. Fifty-eight percent of pharmacists used body mass index to evaluate the appropriateness of DOACs in obese patients whereas 42% used total body weight. Preference for rivaroxaban (31.4%) was higher in this population compared to the global population (10%). Apixaban was preferred for patients with renal impairment (92.2%). However, as creatinine clearance as calculated by the Cockcroft-Gault equation (CrCl) reduced to ≤15 milliliters/minute (mL/min), preference for warfarin increased (36%). Conclusion: This national survey of pharmacists demonstrated an overall preference for apixaban and significant variability in practice patterns regarding DOACs for patients with new VTE, patients with obesity, and patients with renal impairment. Further research is warranted to evaluate the efficacy and safety of DOAC initiation dosing phase modifications. Prospective evaluations of DOACs in obese and renal dysfunction populations would confirm the safety and efficacy of DOACs in these populations.

Project description:Background: The drug therapy of venous thromboembolism (VTE) presents a significant economic burden to the health-care system in low- and middle-income countries. To understand which anticoagulation therapy is most cost-effective for clinical decision-making , the cost-effectiveness of apixaban (API) versus rivaroxaban (RIV), dabigatran (DAB), and low molecular weight heparin (LMWH), followed by vitamin K antagonist (VKA), in the treatment of VTE in China was assessed. Methods: To access the quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs), a long-term cost-effectiveness analysis was constructed using a Markov model with 5 health states. The Markov model was developed using patient data collected from the Xijing Hospital from January 1, 2016 to January 1, 2021. The time horizon was set at 30 years, and a 6-month cycle length was used in the model. Costs and ICERs were reported in 2020 U.S. dollars. One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were used to test the uncertainties. A Chinese health-care system perspective was used. Results: In the base case, the data of 231 VTE patients were calculated in the base case analysis retrospectively. The RIV group resulted in a mean VTE attributable to 95% effective treatment. API, DAB, and VKA have a negative ICER (-187017.543, -284,674.922, and -9,283.339, respectively) and were absolutely dominated. The Markov model results confirmed this observation. The ICER of the API and RIV was negative (-216176.977), which belongs to the absolute inferiority scheme, and the ICER value of the DAB and VKA versus RIV was positive (110,577.872 and 836,846.343). Since the ICER of DAB and VKA exceeds the threshold, RIV therapy was likely to be the best choice for the treatment of VTE within the acceptable threshold range. The results of the sensitivity analysis revealed that the model output varied mostly with the cost in the DAB on-treatment therapy. In a probabilistic sensitivity analysis of 1,000 patients for 30 years, RIV has 100% probability of being cost-effective compared with other regimens when the WTP is $10973 per QALY. When WTP exceeded $148,000, DAB was more cost-effective than RIV. Conclusions: Compared with LMWH + VKA and API, the results proved that RIV may be the most cost-effective treatment for VTE patients in China. Our findings could be helpful for physicians in clinical decision-making to select the appropriate treatment option for VTE.

Project description:BackgroundDabigatran was proven to have similar effect on the prevention of recurrence of venous thromboembolism (VTE) and a lower risk of bleeding compared to vitamin K antagonists (VKA). The aim of this study is to assess the cost-effectiveness (CE) of dabigatran for the treatment and secondary prevention in patients with VTE compared to VKAs in the Dutch setting.MethodsPreviously published Markov model was modified and updated to assess the CE of dabigatran and VKAs for the treatment and secondary prevention in patients with VTE from a societal perspective in the base-case analysis. The model was populated with efficacy and safety data from major dabigatran trials (i.e. RE-COVER, RECOVER II, RE-MEDY and RE-SONATE), Dutch specific costs, and utilities derived from dabigatran trials or other published literature. Univariate, probabilistic sensitivity and a number of scenario analyses evaluating various decision-analytic settings (e.g. the perspective of analysis, use of anticoagulants only for treatment or only for secondary prevention, or comparison to no treatment) were tested on the incremental cost-effectiveness ratio (ICER).ResultsIn the base-case scenario, patients on dabigatran gained an additional 0.034 quality adjusted life year (QALY) while saving €1,598. Results of univariate sensitivity analysis were quite robust. The probability that dabigatran is cost-effective at a willingness-to-pay threshold of €20,000/QALY was 98.1%. From the perspective of healthcare provider, extended anticoagulation with dabigatran compared to VKAs was estimated at €2,158 per QALY gained. The ICER for anticoagulation versus no treatment in patients with equipoise risk of recurrent VTE was estimated at €33,379 per QALY gained. Other scenarios showed dabigatran was cost-saving.ConclusionFrom a societal perspective, dabigatran is likely to be a cost-effective or even cost-saving strategy for treatment and secondary prevention of VTE compared to VKAs in the Netherlands.

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Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients.

Publications

Cost-effectiveness analysis of doctor-pharmacist collaborative prescribing for venous thromboembolism in high risk surgical patients.

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