Cost analysis of pharmaceutical care provided to HIV-infected patients: an ambispective controlled study

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

The economic impact of pharmacist care for people living with HIV/AIDS: A systematic review

Background and objective

Methods

Results

Conclusions

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The role of pharmacists in HIV care is expanding, and it is recommended by the World Health Organization and the American Society of Health-System Pharmacists. Therefore, we attempted to find the economic impact of these services.

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We discovered four such studies, each with minor differences in study intervention, study population, and follow-up duration, making it difficult to generalise their findings.

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Studies have shown that pharmacist interventions have economic benefits; however, future controlled and real world studies to determine the economic benefits, in the long run, are required to strengthen the evidence.

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BACKGROUND

Pharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.

OBJECTIVE

This study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.

METHODS

We identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence. The review protocol was published on PROSPERO (CRD42020167994).

RESULTS

Twenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.

CONCLUSION

The findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.

Remote pharmaceutical care for patients with rheumatoid arthritis and psoriasis

BackgroundAccess to drugs with hospital-restricted dispensation, such as those for patients with rheumatoid arthritis or psoriasis, is regulated by healthcare policy. These drugs have the greatest cost-effective impact on the healthcare system. This is why a model for Pharmaceutical Care based on follow-up teleconsultations was defined in our hospital to improve patient well-being. Objective To evaluate clinical changes on patients when our remote Pharmaceutical Care model is applied and describe the work carried out by pharmacists when applying it. Setting Pharmacy Department of a Hospital in Barcelona, Spain. Method Cross-sectional observational study of the remote Pharmaceutical Care model developed by Clinical Pharmacists. All patients diagnosed with psoriasis or rheumatoid arthritis who were receiving active treatment with Hospital/Specialist only drugs, during the period from May to December 2018, were included. Main outcome measures The corresponding healthcare activity was recorded and to determine the utility of the model, the clinical response to treatment of patients included in the study was recorded. Results The implementation of teleconsultation is statistically related to the biological treatment response of patients with psoriasis (p = 0.006) and rheumatoid arthritis (p = 0.019). In those patients the healthcare activity of calculating and/or recording clinical variables of effectiveness/safety is statistically associated to biological treatment response (65.62% vs 35%, p = 0.015 and 73.14% vs 53.26%, p = 0.003). Conclusions The implementation of the model described lends added value to traditional pharmacotherapeutic management of biological treatments in patients with rheumatoid arthritis and psoriasis since response is improved but patient well-being is not diminished.

Impact of physician-pharmacist collaborative protocol-based pharmacotherapy management for HIV outpatients: a retrospective cohort study

Background

Effective treatment for human immunodeficiency virus (HIV) infection requires close cooperation among healthcare professionals. This is because maintaining continuity with treatment regimens is important in anti-HIV therapy. In addition, explaining medication use is more important than that for other diseases. Since 2010, pharmacists at the Mie University Hospital have been interviewing patients, selecting drugs, and formulating medication plans for HIV-positive patients. In August 2011, we established the physician and pharmacist-led collaborative Protocol-based Pharmacotherapy Management (PBPM) to increase the efficacy and safety of treatment, while reducing the burden on physicians. In the present study, we evaluated the outcomes associated with PBPM for HIV pharmacotherapy.

Methods

We prepared protocols for drug selection, timing of interventions, and methods of intervention according to various guidelines. This study included 40 HIV-positive patients receiving outpatient care between January 2009 and February 2017. Of these patients, 17 received treatment before implementing PBPM and 23 patients received treatment afterward. We compared the intervention parameters between before and after the implementation of PBPM.

Results

The proportion of patients receiving prescription proposals from pharmacists was markedly higher after introducing PBPM (6 out of 17 patients vs. 23 out of 23 patients). All prescription proposals were accepted by physicians before and after PBPM. The number of interviews before antiretroviral therapy (ART) initiation (median [range]) decreased from 2 [1–5] to 1 [1–3] after PBPM introduction, suggesting the time to introduction of treatment has been shortened. Before the introduction of PBPM, nine patients required a change in their ART prescriptions and four patients were hospitalized (one patient was hospitalized due to an error in the self-administration of anti-HIV medicines, two patients were hospitalized due to interruptions in medication, and one patient was hospitalized for the treatment of other diseases). Only one patient was hospitalized after PBPM, and was unrelated to drug adherence. The proportion of patients with a reduced HIV-RNA load increased from 71 to 100%. Furthermore, the proportion of patients who maintained levels below the limit of quantitation increased from 59 to 91% after implementing PBPM.

Conclusion

The implementation of PBPM for HIV outpatients improves the efficacy and safety of HIV pharmacotherapy.

Clinical and Economic Effects of a Pharmacist-Administered Antiretroviral Therapy Adherence Clinic for Patients Living with HIV

BACKGROUND

Pharmacists have demonstrated the ability to improve patient adherence to antiretroviral therapy (ART).

OBJECTIVE

To determine the clinical and economic effects of a pharmacist-administered ART adherence clinic for patients living with human immunodeficiency virus (HIV).

METHODS

This pilot study with a pretest-posttest design examined the effect of a pharmacy adherence clinic on patient HIV viral load and CD4 count over a 6-month period. Patients with documented adherence problems were referred to the clinic. The pharmacist counseled patients at baseline and met with patients 1-2 weeks, 6 weeks, 3 months, and 6 months after starting ART. A societal perspective net cost analysis of the pharmacy adherence clinic was conducted to assess the economic efficiency of the intervention.

RESULTS

Twenty-eight patients were enrolled in the study, and 16 patients reached completion. Median HIV RNA significantly decreased from 48,000 copies/mL (interquartile range [IQR] = 16,750-139,000) to undetectable (< 20 copies/mL) at 6 months for all study participants who completed the full intervention (P = 0.001). In the 3 months following the intervention, we estimated that it prevented approximately 0.13 secondary HIV infections among the sexual partners of the 16 participants who completed the intervention. The total cost of the intervention was $16,811 ($1,051 per patient), which was less than the future savings in averted HIV-related medical care expenditures ($49,702).

CONCLUSIONS

A pharmacy adherence clinic that focused on early and sustained ART adherence interventions helped patients with documented medication adherence problems achieve an undetectable HIV RNA. The intervention was highly cost saving, with a return of nearly $3 in future medical care savings per dollar spent on the intervention.

DISCLOSURES

This work was supported in part by a research grant to Dilworth, Mercier, and Borrego from the American Society of Health-System Pharmacists Foundation. Klein and Pinkerton were supported in part by grants T32-MH19985 and P30-MH52776, respectively, from the National Institute of Mental Health. No funding bodies had any role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Health Resources and Services Administration. The authors have no conflicts of interest to disclose. Study concept and design were contributed primarily by Dilworth, Mercier, and Borrego, along with the other authors. Dilworth took the lead in data collection, along with Pinkerton, Klein, Mercier, and Jakeman. Data interpretation was performed by Dilworth and Pinkerton, along with the other authors. The manuscript was written by Dilworth, Klein, and Jakeman, with assistance from the other authors, and revised by Dilworth, Jakeman, and Klein, with assistance from the other authors. The results from this study were presented in part at the 2015 United States Conference on AIDS in Washington, DC, on September 10-13, 2015.

Reduction of pharmaceutical expenditure by a drug appropriateness intervention in polymedicated elderly subjects in Catalonia (Spain)

OBJECTIVE

To assess the monetary savings resulting from a pharmacist intervention on the appropriateness of prescribed drugs in community-dwelling polymedicated (≥8 drugs) elderly people (≥70 years).

METHOD

An evaluation of pharmaceutical expenditure reduction was performed within a randomised, multicentre clinical trial. The study intervention consisted of a pharmacist evaluation of all drugs prescribed to each patient using the "Good Palliative-Geriatric Practice" algorithm and the "Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment" criteria (STOPP/START). The control group followed the routine standard of care. A time horizon of one year was considered and cost elements included human resources and drug expenditure.

RESULTS

490 patients (245 in each group) were analysed. Both groups experienced a decrease in drug expenditure 12 months after the study started, but this decrease was significantly higher in the intervention group than in the control group (-14.3% vs.-7.7%; p=0.041). Total annual drug expenditure decreased 233.75 €/patient (95% confidence interval [95%CI]: 169.83-297.67) in the intervention group and 169.40 €/patient (95%CI: 103.37-235.43) in the control group over a one-year period, indicating that 64.30 € would be the drug expenditure savings per patient a year attributable to the study intervention. The estimated return per Euro invested in the programme would be 2.38 € per patient a year on average.

CONCLUSIONS

The study intervention is a cost-effective alternative to standard care that could generate a positive return of investment.

HIV pharmaceutical care in primary healthcare: Improvement in CD4 count and reduction in drug-related problems

Background: Highly active antiretroviral therapy (HAART) is complex and many factors contribute to a patient's response to initial therapy including adherence, drug effectiveness, and tolerance. Close HAART follow-up is needed, particularly when there are concurrent therapies such as prophylactic antibiotics and medications for the treatment of comorbidities. Objective: To assess the effectiveness of pharmacist intervention in reducing drug related problems in HIV/AIDS outpatients (intervention group) and in improving clinical parameters in the intervention group compared to the control group. Methods: We conducted a prospective controlled intervention study with patients paired by gender and initial T CD4+ lymphocyte (CD4) count. HIV-infected patients of a public outpatient service were enrolled for the study by consecutive and convenience sampling. Patients selected for the study were divided into a control group and an intervention group. Both groups were followed for one year; however, only the intervention group received pharmaceutical care. The primary outcome was the drug related problem (DRP) analysis for the intervention group. Secondary outcomes were CD4 count and viral load evaluation for both groups. Results: There was a total of 143 patients enrolled in this study, with 53 (37.06%) patients in the control group and 90 (62.94%) patients in the intervention group. A total of 202 pharmacist interventions with 193 pharmacist-patient and 9 pharmacist-physician interventions were proposed. After one year of pharmaceutical care, a reduction of 38.43% between the initial and final DRP was found (p = 0.0001). The most common DRPs found were related to medication safety. The intervention group showed a mean increase of 84% for the CD4 count in comparison with that observed in the control group. The viral load was not significantly different between the final and initial mean values for both groups. Conclusion: Pharmacist appointments enabled identification, prevention, and solving of drug related problems, especially those related to drug safety. Also, pharmacist interventions improved adherence and increased HAART effectiveness as suggested by the higher elevation in the CD4 count seen in the intervention group in comparison with the control group.

Economic Evaluation of Hospital and Community Pharmacy Services

Objective: To review the international body of literature from 2010 to 2015 concerning methods of economic evaluations used in hospital- and community-based studies of pharmacy services in publicly funded health systems worldwide, their clinical outcomes, and economic effectiveness. Data Sources: The literature search was undertaken between May 2, 2015, and September 4, 2015. Keywords included “health economics” and “evaluation” “assessment” or “appraisal,” “methods,” “hospital” or “community” or “residential care,” “pharmacy” or “pharmacy services” and “cost minimisation analysis” or “cost utility analysis” or “cost effectiveness analysis” or “cost benefit analysis.” The databases searched included MEDLINE, PubMed, Google Scholar, Science Direct, Springer Links, and Scopus, and journals searched included PLoS One, PLoS Medicine, Nature, Health Policy, Pharmacoeconomics, The European Journal of Health Economics, Expert Review of Pharmacoeconomics and Outcomes Research, and Journal of Health Economics. Study Selection and Data Extraction: Studies were selected on the basis of study inclusion criteria. These criteria included full-text original research articles undertaking an economic evaluation of hospital- or community-based pharmacy services in peer-reviewed scientific journals and in English, in countries with a publicly funded health system published between 2010 and 2015. Data Synthesis: 14 articles were included in this review. Cost-utility analysis (CUA) was the most utilized measure. Cost-minimization analysis (CMA) was not used by any studies. The limited use of cost-benefit analyses (CBAs) is likely a result of technical challenges in quantifying the cost of clinical benefits, risks, and outcomes. Hospital pharmacy services provided clinical benefits including improvements in patient health outcomes and reductions in adverse medication use, and all studies were considered cost-effective due to meeting a cost-utility (per quality-adjusted life year) threshold or were cost saving. Community pharmacy services were considered cost-effective in 8 of 10 studies. Conclusions: Economic evaluations of hospital and community pharmacy services are becoming increasingly commonplace to enable an understanding of which health care services provide value for money and to inform policy makers as to which services will be cost-effective in light of limited health care resources.

Self-perception of knowledge and adherence reflecting the effectiveness of antiretroviral therapy

OBJECTIVES

To evaluate which indirect method for assessing adherence best reflects highly active antiretroviral therapy (HAART) effectiveness and the factors related to adherence.

METHOD

This descriptive, cross-sectional study was performed in 2012 at a reference center of the state of São Paulo. Self-report (simplified medication adherence questionnaire [SMAQ]) and drug refill parameters were compared to the viral load (clinical parameter of the effectiveness of pharmacotherapy [EP]) to evaluate the EP. The "Cuestionario para la Evaluación de la Adhesión al Tratamiento Antiretroviral" (CEAT-VIH) was used to evaluate factors related to adherence and the EP and, complementarily, patient self-perception of adherence was compared to the clinical parameter of the EP.

RESULTS

Seventy-five patients were interviewed, 60 of whom were considered as adherent from the clinical parameter of the EP and ten were considered as adherent from all parameters. Patient self-perception about adherence was the instrument that best reflected the EP when compared to the standardized self-report questionnaire (SMAQ) and drug refill parameter. The level of education and the level of knowledge on HAART were positively correlated to the EP. Forgetfulness, alcohol use, and lack of knowledge about the medications were the factors most frequently reported as a cause of nonadherence.

CONCLUSION

A new parameter of patient self-perception of adherence, which is a noninvasive, inexpensive instrument, could be applied and assessed as easily as self-report (SMAQ) during monthly drug refill, since it allows monitoring adherence through pharmaceutical assistance. Therefore, patient adherence to HAART could be evaluated using self-perception (CEAT-VIH) and the viral load test.