Community pharmacists workforce readiness to deliver vaccination services: A cross-sectional study from Jordan

This study assesses Jordanian community pharmacists’ readiness and willingness to deliver vaccination services in their practice sites. Between February and April 2021, a self-administered online questionnaire was distributed via social media, WhatsApp messages, and personal communication. The questionnaire targeted practicing community pharmacies. Descriptive and inferential data analysis was carried out. A total of 403 community pharmacists participated in the study. Almost 146 (36%) community pharmacists reported vaccinating patients in their practice sites. However, readiness assessment revealed that only 54 (13.4%) pharmacists received the required training and qualifications. Moreover, 33 (8.2%) study participants worked in adequately equipped and designed community pharmacies. Overall, surveyed participants held positive attitudes toward their involvement in vaccination services: 260 (64.5%) pharmacists were willing to vaccinate patients, and 227 (65.0%) out of unready, unqualified, participants were willing to get needed training and qualifications. According to study participants, regulatory and professional bodies (Ministry of Health, Jordan Pharmacists Association) are influential in supporting pharmacist-vaccinators. Among the investigated factors, organizational structure and employment status were significantly associated with pharmacists’ readiness to deliver vaccination. This study revealed that further work is needed to increase pharmacists’ and pharmacies’ readiness to deliver vaccination services and that regulators should follow a more active approach in highlighting the importance of training and the impact of training in patients’ safety and satisfaction

Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study

Objectives: To assess the long-term cost-effectiveness of a risk stratification pathway, compared with standard care, for detecting non-alcoholic fatty liver disease (NAFLD) in primary care. Setting: Primary care general practices in England. Participants: Adults who have been identified in primary care to have a risk factor for developing NAFLD, that is, type 2 diabetes without a history of excessive alcohol use. Intervention: A community-based pathway, which utilises transient elastography and hepatologists to stratify patients at risk of NAFLD, has been implemented and demonstrated to be feasible (NCT02037867). Earlier identification could mean earlier treatments, referral to specialist, and enrolment into surveillance programmes. Design: The impact of earlier detection and treatment with the risk stratification pathway on progression to later stages of liver disease was examined using decision modelling with Markov chains to estimate lifetime health and economic effects of the two comparators. Data sources: Data from a prospective cross-sectional feasibility study indicating risk stratification pathway and standard care diagnostic accuracies, were combined with a Markov model that comprised the following states: no/mild liver disease, significant liver disease, compensated cirrhosis; decompensated cirrhosis, hepatocellular carcinoma, liver transplant and death. The model data were chosen from up-to-date UK sources, published literature and an expert panel. Outcome measure: An incremental cost-effectiveness ratio (ICER) indicating cost per quality adjusted life year (QALY) of the risk stratification pathway compared with standard care was estimated. Results: The risk stratification pathway was more effective than standard care, and cost ￡2,138 per QALY gained. The ICER was most sensitive to estimates of the rate of fibrosis progression and the effect of treatment on reducing this, and ranged from -￡1,895 to ￡7,032/QALY. The risk stratification pathway demonstrated an 85% probability of cost-effectiveness at the UK willingness-to-pay threshold of ￡20,000/QALY. Conclusions: Implementation of a community-based risk stratification pathway is likely to be cost effective

Cost-effectiveness of a specialist geriatric medical intervention for frail older people discharged from acute medical units: economic evaluation in a two-centre randomised controlled trial (AMIGOS)

Background Poor outcomes and high resource-use are observed for frail older people discharged from acute medical units. A specialist geriatric medical intervention, to facilitate Comprehensive Geriatric Assessment, was developed to reduce the incidence of adverse outcomes and associated high resource-use in this group in the post-discharge period. Objective To examine the costs and cost-effectiveness of a specialist geriatric medical intervention for frail older people in the 90 days following discharge from an acute medical unit, compared with standard care. Methods Economic evaluation was conducted alongside a two-centre randomised controlled trial (AMIGOS). 433 patients (aged 70 or over) at risk of future health problems, discharged from acute medical units within 72 hours of attending hospital, were recruited in two general hospitals in Nottingham and Leicester, UK. Participants were randomised to the intervention, comprising geriatrician assessment in acute units and further specialist management, or to control where patients received no additional intervention over and above standard care. Primary outcome was incremental cost per quality adjusted life year (QALY) gained. Results We undertook cost-effectiveness analysis for 417 patients (intervention: 205). The difference in mean adjusted QALYs gained between groups at 3 months was -0.001 (95% confidence interval [CI]: -0.009, 0.007). Total adjusted secondary and social care costs, including direct costs of the intervention, at 3 months were £4412 (€5624, $6878) and £4110 (€5239,$6408) for the intervention and standard care groups, the incremental cost was £302 (95% CI: 193, 410) [€385, $471]. The intervention was dominated by standard care with probability of 62%, and with 0% probability of cost-effectiveness (at £20,000/QALY threshold). Conclusions The specialist geriatric medical intervention for frail older people discharged from acute medical unit was not cost-effective. Further research on designing effective and cost-effective specialist service for frail older people discharged from acute medical units is needed

Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes

BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM)

Cost effectiveness of support for people starting a new medication for a long term condition through community pharmacies: an economic evaluation of the New Medicine Service (NMS) compared with normal practice

Background: The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost-effectiveness of NMS compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs. Methods: We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients’ non-adherence. Clinical event probability, treatment pathway, resource-use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted-life-year(QALY) were calculated from the perspective of NHS England, using a lifetime horizon. Results: NMS generated a mean of 0.05 (95%CI: 0.00, 0.13) more QALYs per patient, at a mean reduced cost of -£144 (95%CI: -769, 73). The NMS dominates normal practice with probability of 0.78 (ICER: - £3166 per QALY). NMS has a 96.7% probability of cost-effectiveness compared with normal practice at a willingness-to-pay of £20000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost-effectiveness compared with normal practice at a willingness-to-pay of £20000 per QALY. Conclusions: Our study suggests that the New Medicine Service increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost

Investigating the cost-effectiveness of antiplatelet medications in patients with type 2 diabetes for the secondary prevention of acute coronary syndromes

Acute Coronary Syndrome (ACS) is a condition with very high clinical burden and financial burden worldwide and in the UK. ACS is more common in populations with Type 2 Diabetes Mellitus(T2DM), due to the vascular complications that people with T2DM face. This fact results in increased occurrence of ACS compared to the general population. ACS management is complex in T2DM populations because of the additional need for glycaemic control. Oral antiplatelet medication (clopidogrel, aspirin) is among the most important treatments for the secondary prevention of ACS. New oral antiplatelet agents (ticagrelor, prasugrel) were compared as alternative treatments to clopidogrel in the general population. The new agents performed better than clopidogrel in terms of effectiveness and cost-effectiveness. The results of the effectivess of those agents in T2DM subgroups were available, but they were presented as an ad hoc analysis of the initial trials. This gap in research provided an opportunity for investigating effectiveness of antiplatelet medications in T2DM populations using real world data. This study investigated the economic impact of different antiplatelet regimens in people with T2DM post-ACS, from the perspective of the NHS in England. The study aimed to gain an understanding of the characteristics of people with T2DM prescribed antiplatelet medications for secondary prevention post-ACS (demographics, clinical outcomes, medication usage, medication adherence, healthcare resource used, and costs), explain the variation in those clinical outcomes and costs, and investigate the effectiveness and cost-effectiveness of antiplatelet regimens in this population. Using routinely collected data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), a cohort study was carried out in order to investigate the effect of different antiplatelet regimens in patients with T2DM. Inverse probability treatment weights were obtained from propensity score models, and those weights were used to address the confounding that arised from the non-random assignment in antiplatelet regimens in the retrospectively observed data. The time to event analysis found that the newer antiplatelet medications had better results than aspirin-clopidogrel for the outcomes investigated. The time to reccurence of a major adverse cardiovascular event (MACE) in patients treated with aspirin-prasugrel was approximately 4.4 times longer [Time Ratio (TR): 4.42; 95%CI: 1.73 to 11.28] compared to that of patients on aspirin-clopidogrel. No effect was found in patients who were prescribed aspirin-ticagrelor. Aspirin-prasugrel was associated with a 96% decrease in the hazard rate of stroke [Hazard Ratio (HR): 0.04 ;95% CI: 0.01 to 0.32] and aspirin-ticagrelor with a 78% decrease [Hazard Ratio (HR): 0.22 ;95% CI: 0.05 to 0.95] when compared with aspirin-clopidogrel. The time to recurrence of a bleeding event in patients on aspirin-ticagrelor was approximately 12 times longer compared to that of patients on aspirin-clopidogrel [TR:11.89; 95%CI: 0.95 to 148.03]. No effect in bleeding was found in patients who were prescribed aspirin-prasugrel. Patients on aspirin-ticagrelor and aspirin-prasugrel survived 2.6 times [TR: 2.57;95% CI: 1.61 to 4.12] and 1.4 times longer [TR: 1.43;95% CI: 1.01 to 2.06] compared to patients treated with aspirin-clopidogrel. The findings are in partial accordance with the literature around the effectiveness of newer antiplatelet agents versus aspirin-clopidogrel. The cost association analysis found that, on average, patients on aspirin-ticagrelor and aspirin-clopidogrel incur annually £6345 in total care health care costs. Patients on aspirin-prasugrel incurred 35% less costs (£4098). The adherence analysis found that the average proportion of days covered (PDC) for all regimens is high and above the cut-off point of 80%. Patients on dual antiplatelet therapy regimens started discontinuing their therapies after 180 days. For the groups of aspirin- ticagrelor and aspirin-prasugrel there where no patients continuing their prescription after 450 days. In the aspirin-clopidogrel group the number of patients with prescriptions lasting more than 450 days was decreasing and the number of patients continuing with therapy for more than 450 days and less than 720 days was very small. A decision analytical model was used to estimate the cost-effectiveness of alternative dual antiplatelet regimens and aspirin only. The analysis demonstrated that aspirin-ticagrelor generated more QALYs [0.67;95% CI:0.05 to 1.22] compared with aspirin only and costs [£1459.96; 95% CI: -5797.66 to 10056.77] over the lifetime horizon. Aspirin-prasugrel and aspirin-clopidogrel were extendedly dominated. The probabilistic model estimated that aspirin-ticagrelor had the highest probability of being cost-effective for willingness to pay levels higher than £2000 per QALY. For a maximum willingness-to pay of £20000 per QALY the probability of cost-effectiveness was 90%. These findings were in accordance with similar studies for the general population. This study allowed for a head-to-head comparison of alternative antiplatelet regimens for T2DM patients who suffered an ACS. Study findings were relevant for England only and not UK wide, because of the linkage of primary and secondary care data. The time-to-event and the cost analyses, even though they were carried out with the use of doubly robust estimation methods, potentially did not sufficiently address some of the confounding. In the Markov model, it was not possible to use a more complex treatment pattern in the patients who were assigned in DAPT regimen, and that could result in the potential overestimation cost-effectiveness. Many T2DM patients were on monotherapy regimens for secondary prevention, even though this is not suggested in the clinical guidelines. Further investigation for this specific group is needed. T2DM patients who are on a DAPT regimen, tend to discontinue the treatment from the sixth month. This practice implication indicates the need for interventions that reduce DAPT discontinuation

Investigating the cost-effectiveness of antiplatelet medications in patients with type 2 diabetes for the secondary prevention of acute coronary syndromes

Acute Coronary Syndrome (ACS) is a condition with very high clinical burden and financial burden worldwide and in the UK. ACS is more common in populations with Type 2 Diabetes Mellitus(T2DM), due to the vascular complications that people with T2DM face. This fact results in increased occurrence of ACS compared to the general population. ACS management is complex in T2DM populations because of the additional need for glycaemic control. Oral antiplatelet medication (clopidogrel, aspirin) is among the most important treatments for the secondary prevention of ACS. New oral antiplatelet agents (ticagrelor, prasugrel) were compared as alternative treatments to clopidogrel in the general population. The new agents performed better than clopidogrel in terms of effectiveness and cost-effectiveness. The results of the effectivess of those agents in T2DM subgroups were available, but they were presented as an ad hoc analysis of the initial trials. This gap in research provided an opportunity for investigating effectiveness of antiplatelet medications in T2DM populations using real world data. This study investigated the economic impact of different antiplatelet regimens in people with T2DM post-ACS, from the perspective of the NHS in England. The study aimed to gain an understanding of the characteristics of people with T2DM prescribed antiplatelet medications for secondary prevention post-ACS (demographics, clinical outcomes, medication usage, medication adherence, healthcare resource used, and costs), explain the variation in those clinical outcomes and costs, and investigate the effectiveness and cost-effectiveness of antiplatelet regimens in this population. Using routinely collected data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), a cohort study was carried out in order to investigate the effect of different antiplatelet regimens in patients with T2DM. Inverse probability treatment weights were obtained from propensity score models, and those weights were used to address the confounding that arised from the non-random assignment in antiplatelet regimens in the retrospectively observed data. The time to event analysis found that the newer antiplatelet medications had better results than aspirin-clopidogrel for the outcomes investigated. The time to reccurence of a major adverse cardiovascular event (MACE) in patients treated with aspirin-prasugrel was approximately 4.4 times longer [Time Ratio (TR): 4.42; 95%CI: 1.73 to 11.28] compared to that of patients on aspirin-clopidogrel. No effect was found in patients who were prescribed aspirin-ticagrelor. Aspirin-prasugrel was associated with a 96% decrease in the hazard rate of stroke [Hazard Ratio (HR): 0.04 ;95% CI: 0.01 to 0.32] and aspirin-ticagrelor with a 78% decrease [Hazard Ratio (HR): 0.22 ;95% CI: 0.05 to 0.95] when compared with aspirin-clopidogrel. The time to recurrence of a bleeding event in patients on aspirin-ticagrelor was approximately 12 times longer compared to that of patients on aspirin-clopidogrel [TR:11.89; 95%CI: 0.95 to 148.03]. No effect in bleeding was found in patients who were prescribed aspirin-prasugrel. Patients on aspirin-ticagrelor and aspirin-prasugrel survived 2.6 times [TR: 2.57;95% CI: 1.61 to 4.12] and 1.4 times longer [TR: 1.43;95% CI: 1.01 to 2.06] compared to patients treated with aspirin-clopidogrel. The findings are in partial accordance with the literature around the effectiveness of newer antiplatelet agents versus aspirin-clopidogrel. The cost association analysis found that, on average, patients on aspirin-ticagrelor and aspirin-clopidogrel incur annually £6345 in total care health care costs. Patients on aspirin-prasugrel incurred 35% less costs (£4098). The adherence analysis found that the average proportion of days covered (PDC) for all regimens is high and above the cut-off point of 80%. Patients on dual antiplatelet therapy regimens started discontinuing their therapies after 180 days. For the groups of aspirin- ticagrelor and aspirin-prasugrel there where no patients continuing their prescription after 450 days. In the aspirin-clopidogrel group the number of patients with prescriptions lasting more than 450 days was decreasing and the number of patients continuing with therapy for more than 450 days and less than 720 days was very small. A decision analytical model was used to estimate the cost-effectiveness of alternative dual antiplatelet regimens and aspirin only. The analysis demonstrated that aspirin-ticagrelor generated more QALYs [0.67;95% CI:0.05 to 1.22] compared with aspirin only and costs [£1459.96; 95% CI: -5797.66 to 10056.77] over the lifetime horizon. Aspirin-prasugrel and aspirin-clopidogrel were extendedly dominated. The probabilistic model estimated that aspirin-ticagrelor had the highest probability of being cost-effective for willingness to pay levels higher than £2000 per QALY. For a maximum willingness-to pay of £20000 per QALY the probability of cost-effectiveness was 90%. These findings were in accordance with similar studies for the general population. This study allowed for a head-to-head comparison of alternative antiplatelet regimens for T2DM patients who suffered an ACS. Study findings were relevant for England only and not UK wide, because of the linkage of primary and secondary care data. The time-to-event and the cost analyses, even though they were carried out with the use of doubly robust estimation methods, potentially did not sufficiently address some of the confounding. In the Markov model, it was not possible to use a more complex treatment pattern in the patients who were assigned in DAPT regimen, and that could result in the potential overestimation cost-effectiveness. Many T2DM patients were on monotherapy regimens for secondary prevention, even though this is not suggested in the clinical guidelines. Further investigation for this specific group is needed. T2DM patients who are on a DAPT regimen, tend to discontinue the treatment from the sixth month. This practice implication indicates the need for interventions that reduce DAPT discontinuation

Econometric estimation of WHO-CHOICE country-specific costs for inpatient and outpatient health service delivery

Abstract Background Policy makers require information on costs related to inpatient and outpatient health services to inform resource allocation decisions. Methods Country data sets were gathered in 2008–2010 through literature reviews, website searches and a public call for cost data. Multivariate regression analysis was used to explore the determinants of variability in unit costs using data from 30 countries. Two models were designed, with the inpatient and outpatient models drawing upon 3407 and 9028 observations respectively. Cost estimates are produced at country and regional level, with 95% confidence intervals. Results Inpatient costs across 30 countries are significantly associated with the type of hospital, ownership, as well as bed occupancy rate, average length of stay, and total number of inpatient admissions. Changes in outpatient costs are significantly associated with location, facility ownership and the level of care, as well as to the number of outpatient visits and visits per provider per day. Conclusions These updated WHO-CHOICE service delivery unit costs are statistically robust and may be used by analysts as inputs for economic analysis. The models can predict country-specific unit costs at different capacity levels and in different settings