Improving Adherence to Lipid-Lowering Therapy in a Community Pharmacy Intervention Program: A Cost-Effectiveness Analysis

RESEARCH Improving Adherence to Lipid-Lowering Therapy in a Community Pharmacy Intervention Program: A Cost-Effectiveness Analysis Stefan Vegter, PharmD, PhD; Piter Oosterhof, PharmD; Job F.M. van Boven, PharmD; Ada G.G. Stuurman-Bieze, PharmD, PhD; Eric G. Hiddink, PharmD, MScBA; and Maarten J. Postma, PhD ABSTRACT BACKGROUND: Pharmaceutical care in community pharmacies has been shown to improve adherence to chronic therapies. Long-term impact on clinical outcomes or medical cost savings, however, remains understudied. OBJECTIVE: To estimate the cost-effectiveness of a pharmaceutical care intervention program in Dutch community pharmacies that improved patients’ adherence to lipid-lowering therapy. METHODS: An economic evaluation was performed using a time-dependent Markov model from the health care payer perspective. Participants were patients initiating lipid-lowering therapy for primary prevention (40%) or secondary prevention (60%) of cardiovascular events (CVEs). The intervention was the pharmaceutical care program MeMO (Medication Monitoring and Optimisation) in 9 community pharmacies in the Netherlands, based on continuous monitoring and optimization of lipid-lowering therapy in new patients. The follow-up period of the program was 1 year. The main outcome of the intervention program was discontinuation of lipid-lowering therapy. This outcome was extrapolated in the economic model to lifelong costs, quality of life, reductions in cardiovascular events, and incremental cost-effectiveness ratios. RESULTS: Patients in the MeMO program had a lower risk for therapy discontinuation, RR = 0.49 (0.37 to 0.66); the effectiveness was similar in primary and secondary prevention. In a cohort of 1,000 primary and secondary prevention patients, the MeMO program resulted in a reduction of 7 nonfatal strokes, 2 fatal strokes, 16 nonfatal myocardial infarctions (MIs), 7 fatal MIs, and 16 revascularizations over patients’ lifetime. Additional medication, disease management, and intervention costs in the MeMO program were € 411,000; the cost savings due to reduced CVEs were € 443,000. The MeMO program resulted in 84 quality-adjusted life-years (QALYs) gained and net cost savings of € 32,000. Clinical benefits and cost savings were highest in the secondary prevention population. CONCLUSION: Pharmaceutical care in community pharmacies can improve statin therapy adherence, resulting in better prevention of CVEs. The MeMO program resulted in considerable clinical benefits and net cost savings. Programs by community pharmacies targeted at improving adherence may provide good value for money, and health care insurers should consider reimbursing these activities. J Manag Care Pharm. 2014;20(7):722-32 Copyright © 2014, Academy of Managed Care Pharmacy. All rights reserved. What is already known about this subject • Cardiovascular events, such as myocardial infarction and stroke, are a main cause of death and morbidity in most developed countries. • Lipid-lowering therapy reduces the risk for cardiovascular events; however, therapy adherence in clinical practice is low. • Pharmaceutical care in community pharmacies has been shown to improve adherence to chronic therapies, including lipid-lowering therapy. 722 Journal of Managed Care & Specialty Pharmacy JMCP July 2014 What this study adds • A Dutch pharmaceutical care program in community pharmacies led to increased adherence to lipid-lowering therapy. • The pharmaceutical care program was modeled to result in considerable clinical benefits, including reduced cardiovascular events, increased quality of life, and added life-years. • Despite intervention costs and increased medication costs, the pharmaceutical care program led to net cost savings. C ardiovascular events, predominantly myocardial infarction and stroke, are a main cause of death and morbidity in most developed countries.1 Dyslipidemia is a major risk factor for cardiovascular events (CVEs). Lipid-lowering therapy, specifically statins, have become a cornerstone of treatment for dyslipidemia due to their marked lowering of low-density lipoprotein cholesterol (LDL).2 Indeed, statins have demonstrated considerable efficacy in reducing myocardial infarction (MI), stroke, and costly revascularization procedures.3,4 The clinical benefits of statin therapy are largest for secondary prevention of CVEs, that is, for patients who already experienced a CVE.5,6 Also, as primary prevention, statin therapy reduces the risk for CVE, although the absolute risk reduction is smaller due to the lower baseline risk in this population.7,8 The relative risk reduction of CVEs is around 30%, regardless of age, sex, prior history of CVEs, or other comorbid conditions, such as diabetes mellitus type 2 (DM2).2 Contrasting with the high therapy adherence often achieved in clinical trial settings, adherence to lipid-lowering medication in real-world settings is often suboptimal, and many patients discontinue therapy.9,10 The promising results of clinical trials may therefore not be achieved in real-world settings.11 Discontinuation of cardiovascular medication obviously leads to lower drug costs, but these cost savings are more than offset by increased medical costs of CVEs.12,13 Although novel drugs may improve cardiovascular outcomes in the future, increasing therapy adherence to currently available drugs is at least equally important to optimize therapy.14 As a common place of interaction between patients and health care professionals, community pharmacies provide a promising setting for pharmaceutical care aimed to increase therapy adherence. In the Netherlands, the MeMO (Medication Vol. 20, No. 7 www.amcp.org Improving Adherence to Lipid-Lowering Therapy in a Community Pharmacy Intervention Program: A Cost-Effectiveness Analysis FIGURE 1 TABLE 1 Model Structure Primary Prevention MI Diabetes Mellitus High Riska Post-MI DM2 High Risk MI Post-Stroke Stroke a High-risk patients were defined as patients with coronary disease except MI or other occlusive arterial disease.5 DM2 = type 2 diabetes mellitus; MI = myocardial infarction. Monitoring and Optimisation) program has been an ongoing pharmaceutical care program since 2006, focusing on osteoporosis, asthma/chronic obstructive pulmonary disease, cardiovascular disease, DM2, and depression.15 In particular, the program is targeted at the monitoring and optimization of chronic therapy use. The clinical and economic benefits of MeMO have been demonstrated for bisphosphonate use in osteoporosis.16,17 Recently, the efficacy of the MeMO program in reducing discontinuation of lipid-lowering therapy was demonstrated.18 In the Netherlands in 2008, large-scale and often mandatory generic substitution policies have been installed for many chronic medications, including lipid-lowering drugs. The ensuing competitive bidding strategies led to considerable price reductions of these generics. For example, the average list price for simvastatin (...truncated)