Is comprehensive medication review cost-effective for patients admitted to hospital?

Abstract

Problematic polypharmacy is a major public health problem, linked to high morbidity, mortality and use of National Health Service (NHS) resources. Medicines optimisation supports management of polypharmacy, chronic conditions and comorbidities by ensuring appropriate use of medicines. A key component is comprehensive medication review (CMR) – evaluating patients’ medication to optimise use and reduce medication-related problems and waste. CMR is recommended for problematic polypharmacy but its cost-effectiveness in UK hospitals is unknown and uptake is low. This thesis investigates CMR cost-effectiveness in UK NHS hospitals. CMR is complex, with multiple interacting components, and economic evaluation should accommodate the context and complexity. Two de novo cost-effectiveness models were developed, which demonstrated that CMR compared to usual care is a cost-effective use of resources for the general population of elderly acutely hospitalised patients over a short timeframe and for elderly patients with heart failure over a long timeframe. Analysis of data from 3,043 patients in five London hospitals revealed the difference between the number of medicines on discharge and the number of medicines on admission was less with CMR than with usual care. CMR was associated with an increase in the number of medicines deprescribed, held and started. The saving from deprescribing medicines was -£2.78 per month per patient larger in the CMR group than in the usual care group. The results of the empirical study complement the findings from both cost-effectiveness models. Further review and analysis showed that targeting CMR at patients with significant morbidity and mortality, potentially inappropriate prescribing and high treatment costs may increase its health and economic impact. This was exemplified by the cost-effectiveness of CMR for patients with heart failure; the study could be replicated for other diseases. This thesis indicates that well-delivered CMR should be routine hospital care for older patients with co-morbidity and/or specific target conditions.