Cost-effectiveness of a structured medication review approach for multimorbid older adults: Within-trial analysis of the OPERAM study

• Published in: PloS one 2022-04, Vol.17 (4), p.e0265507-e0265507
• Main Authors: Salari, Paola, O'Mahony, Cian, Henrard, Séverine, Welsing, Paco, Bhadhuri, Arjun, Schur, Nadine, Roumet, Marie, Beglinger, Shanthi, Beck, Thomas, Jungo, Katharina Tabea, Byrne, Stephen, Hossmann, Stefanie, Knol, Wilma, O'Mahony, Denis, Spinewine, Anne, Rodondi, Nicolas, Schwenkglenks, Matthias
• Format: Article
• Language: English
• Subjects: Adults; Aged; Algorithms; Clinical trials; Clusters; Comorbidity; Confidence intervals; Cost analysis; Cost benefit analysis; Drug therapy; Evaluation; Health care policy; Heterogeneity; Hospitalization; Hospitals; Humans; Intervention; Medical care, Cost of; Medication Review; Medicine and Health Sciences; Morbidity; Multimorbidity; Multivariate statistical analysis; Nursing homes; Older people; Optimization; Patient admissions; Patients; People and places; Pharmacists; Pharmacology; Physical Sciences; Polypharmacy; Purchasing power parity; Quality of Life; Research and Analysis Methods; Robustness (mathematics); Social Sciences; Statistical analysis; Subgroups
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0265507

Inappropriate polypharmacy has been linked with adverse outcomes in older, multimorbid adults. OPERAM is a European cluster-randomized trial aimed at testing the effect of a structured pharmacotherapy optimization intervention on preventable drug-related hospital admissions in multimorbid adults with polypharmacy aged 70 years or older. Clinical results of the trial showed a pattern of reduced drug-related hospital admissions, but without statistical significance. In this study we assessed the cost-effectiveness of the pharmacotherapy optimisation intervention. We performed a pre-planned within-trial cost-effectiveness analysis (CEA) of the OPERAM intervention, from a healthcare system perspective. All data were collected within the trial apart from unit costs. QALYs were computed by applying the crosswalk German valuation algorithm to EQ-5D-5L-based quality of life data. Considering the clustered structure of the data and between-country heterogeneity, we applied Generalized Structural Equation Models (GSEMs) on a multiple imputed sample to estimate costs and QALYs. We also performed analyses by country and subgroup analyses by patient and morbidity characteristics. Trial-wide, the intervention was numerically dominant, with a potential cost-saving of CHF 3'588 (95% confidence interval (CI): -7'716; 540) and gain of 0.025 QALYs (CI: -0.002; 0.052) per patient. Robustness analyses confirmed the validity of the GSEM model. Subgroup analyses suggested stronger effects in people at higher risk. We observed a pattern towards dominance, potentially resulting from an accumulation of multiple small positive intervention effects. Our methodological approaches may inform other CEAs of multi-country, cluster-randomized trials facing presence of missing values and heterogeneity between centres/countries.