Open Access Research Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital Ola Ghatnekar,1 Åsa Bondesson,2 Ulf Persson,1 Tommy Eriksson3 Tocite:GhatnekarO, ABSTRACT ARTICLE SUMMARY BondessonÅ,PerssonU, Objective:Toevaluatethecosteffectivenessofa etal.Healtheconomic multidisciplinaryteamincludingapharmacistfor Article focus evaluationoftheLund IntegratedMedicines systematicmedicationreviewandreconciliationfrom ▪ The LIMM model involves systematic patient ManagementModel(LIMM) admissiontodischargeathospitalamongelderly centred and team-based activities and structured inelderlypatientsadmittedto patients(theLundIntegratedMedicinesManagement toolsformedicationreview,includingmedication hospital.BMJOpen2013;3: (LIMM))inordertoreducedrug-relatedreadmissions reconciliation. e001563.doi:10.1136/ andoutpatientvisits. ▪ The model has been extensively investigated and bmjopen-2012-001563 Method:PublisheddatafromtheLIMMprojectgroup shown important improvements in the care wereusedtodesignaprobabilisticdecisiontreemodel processandonsomepatientoutcomes. ▸ Prepublicationhistoryfor forevaluatingtoolsfor(1)asystematicmedication ▪ This study investigated the cost utility of the thispaperareavailable reconciliationandreviewprocessatinitialhospital modelbasedondatafromthreeLIMMstudies. online.Toviewthesefiles admissionandduringstay(admissionpart)and(2)a pleasevisitthejournalonline medicationreportforpatientsdischargedfromhospital Key messages (http://dx.doi.org/10.1136/ toprimarycare(dischargepart).Thecomparatorwas ▪ The study was shown to generate both cost bmjopen-2012-001563). standardcare.Inpatient,outpatientandstafftimecosts savingsandhigherutilitytothepatients. (Euros,2009)werecalculatedduringa3-month ▪ Investing €39 in clinical pharmacist time could Received29May2012 period.Dis-utilitiesforhospitalreadmissionsand save €340 in medical care at hospital and in Revised28November2012 outpatientvisitsduetomedicationerrorsweretaken primary care, as well as in administrative costs Accepted29November2012 fromtheliterature. for correcting errors in medication lists in Thisfinalarticleisavailable Results:ThetotalcostfortheLIMMmodelwas€290 primaryandmunicipalitycareafterdischarge. foruseunderthetermsof comparedto€630forstandardcare,inspiteofa€39 Strengths and limitations of this study theCreativeCommons interventioncost.Themaincostoffsetarosefrom ▪ All bias and confounders could not be ruled out AttributionNon-Commercial avoideddrug-relatedreadmissionsintheAdmission since not all included studies were not rando- 2.0Licence;see part (€262)whereasonly€66wasoffsetinthe http://bmjopen.bmj.com misedandcontrolled. Dischargepartasaresultoffeweroutpatientvisitsand ▪ Utilitiesweretakenfromtheliteratureandmaynot correctiontime.Thereduceddisutilitywasestimatedto entirelyreflecttheanalysedpatientpopulation. 0.005quality-adjustedlife-years(QALY),indicatingthat ▪ Cost savings were shown to be stable also in LIMMwasadominantalternative.Theprobabilitythat several sensitivity analyses which indicated that theinterventionwouldbecost-effectiveatazero theseshortcomingsmaybeoflessimportance. willingnesstopayforagainedQALYcomparedto standardcarewasestimatedto98%. Conclusions:TheLIMMmedicationreconciliation(at achieve in clinical practice. Poorcommunica- admissionanddischarge)andmedicationreviewwas tion of medical information at transition 1SwedishInstituteforHealth bothcost-savingandgeneratedgreaterutility points between care givers has been shown comparedtostandardcare,foremostowingtoavoided Economics,Lund,Sweden responsible foras manyas50% ofall medica- 2DepartmentofMedicines drug-relatedhospitalreadmissions.When tion errors in the hospital and up to 20% of implementingsuchareviewprocesswitha ManagementandInformatics, adverse drug events.1 Adverse drug effects CountyofSkåne,Malmö, multidisciplinaryteam,itmaybeimportanttoconsider are between the fourth and sixth leading Sweden alearningcurveinordertocapturethefulladvantage. 3DepartmentforLaboratory causes of death in the USA2 and for every Medicine,Institutionfor dollar spent on drugs in US nursing home LaboratoryMedicine,Lund facilities; $1.33 in healthcare resources are University,Lund,Sweden consumed in the treatment of drug-related INTRODUCTION problems.3 In systematic reviews, it is Correspondenceto: Dr OlaGhatnekar; The full value of medications as shown in reported that up to 41% of the hospital [email protected] studies with single drugs is difficult to admissions are caused by adverse drug GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 1 Health economic evaluation of the LIMM model reactions and that the majority of these can be pre- METHODS vented, among the elderly up to 90%.2 4 In addition, We designed a probabilistic decision tree model in MS Hohl et al5 report that index hospitalisations due to Excel 2010 forevaluating tools for (1) a systematic medi- adverse drug events are 0.5–4 times longer. Their esti- cation reconciliation and review process at initial hos- mates of cost differences were US$233 (=171€) between pital admission in order to avoid drug-related hospital patients presenting with and without adverse drug readmission due to medication errors (Admission part) events. In Sweden, 6–16% of hospital admissions are and (2) a medication report for patients discharged reported to be medication related and the costs for from hospital to primary care in order to reduce the avoidable drug-related harms have been calculated at medication errors with subsequent outpatient contacts SEK5.6–24.6 billion (€0.6–2.5 billion) annually.6 and hospitalisations as a consequence (Discharge part) Recently randomised controlled studies showed reduc- (figure 1). The model estimated costs and utility loss tions in drug-related inpatient and outpatient readmis- from medication errors needing medical attention sions, reduced hospital stay and improved health-related within a 3-month time period, in line with the follow-up quality of life.7–9 The economic effects of these out- in the underlying data. No discounting was therefore comes have been studied, and in two review studies, it performed. All clinical data were based on studies per- was concluded that clinical pharmacist interventions are formed by the LIMM-research group at Skåne University associated with cost savings, although the mixed meth- Hospital in Lund and at Landskrona Hospital with a odological quality limited the overall conclusions.10 11 total catchment area of more than 300000 inhabitants. However, the cost for pharmacy services for avoiding Costs were based on actual resource use (patient charts) one death in hospitals was calculated at $320 and each and time analysis studies for medical report reviews and dollar spent on clinical pharmacy services gave $4.8 in expressed in Euros, 2009 prices. Utility loss in terms of return.12 13 A UK-based study concluded that QALY for the conditions that needed medical attention pharmacist-led medication reconciliation intervention weretakenfromtheliterature.Probabilities,unitcosts,dis- had the highest expected net benefit compared to utility weights and distributions are presented in table 1. nurse-led and physician-led interventions. The probabil- Costs relevant for the county council and municipality ity of being cost-effective at a societal willingness to pay care were used. Indirect costs for production losses were for a quality-adjusted life-year (QALY) of £10000 was not considered as the analysed cohort was assumed to be estimated to be over 60%.14 Another UK pharmaceutical retired. A probabilistic sensitivity analysis (PSA) was per- care study estimated the incremental cost to £10000 per formed with 10000 iterations.Admission part: medication QALY gained.15 In contrast, an economic evaluation per- reconciliation and review process at initial hospital formed alongside a randomised controlled study showed admission that inhospital clinical pharmacist service was not cost- In a study by Hellström et al,6 a systematic medication effectivein aSwedish healthcaresetting.16 reconciliation and review process at initial hospital We have developed the LIMM (Lund Integrated admission and discharge was evaluated (among 109 Medicines Management) model, a systematic approach patients) compared with standard care with medication to individualise and optimise drug treatment in elderly reconciliation upon discharge (101 patients). Nine and patients admitted to hospital. It starts at admission, con- 12patients, respectively, deceased before hospital dis- tinue during hospital stay and ends with a summary charge. Of those surviving discharge, hospital written for the patient and communicated with the re-admissions with a ‘certain’, ‘probable’ or ‘possible’ patient, the primary and/or community care at dis- causality assessment, occurred in 12 and 6 patients, charge. The LIMM model involves systematic activities respectively (absolute risk reduction=6.9%) during the based on structured and evidence-based tools for 3-month follow-up. Medication Review, including Medication Reconciliation. Based on a time study and schedule calculation study, Clinical pharmacists work in a multiprofessional team, the pharmacist spent on average 65min/patient in close collaboration with ward physicians, nurses, (assumption; SD=20% of mean) for the medication carers and paramedics. This model is the base for three review process in the intervention arm.26 Time spent by PhD dissertations and has been shown to improve physicians and nurses in the control arm was estimated process and patient outcomes such as improving the to 44min and 17min, respectively, based on time appropriateness in the patient’s drug treatment,6 17 studies at the neighbouring Malmö Hospital where the identify and reduce drug-related problems18–20 and LIMMmodel was not practiced.26 medication errors,21–24 and reduce the need for health- carecontactscaused by medication errors.6 25 Dischargepart: medication report atdischarge The aim of this study was to develop a health eco- from hospital nomic model to study the cost-utility of the LIMM Midlöv et al25 studied the difference in need for medical model, that is, taking into account the health-related care due to medication error among patients with and quality of life aspects. With such an analytical tool, it withoutamedicationreportatdischargefromhospitalto would be possible to determine how much the different a nursing home or theirown homewith nurse assistance activities contribute tocosts and effects. for drug dispensing. Using the same WHO criteria as 2 GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 Health economic evaluation of the LIMM model Figure1 Schematicdescription ofthedecisiontreeevaluatingthe costeffectivenessoftheLund IntegratedMedicines Managementmodelversus standardcare. described above, they found that 11 of 248 prospective patients (I:52; C:63).25 We used this reduction in relative patients (4.4%) in the intervention arm (I) experienced risk to adjust the probability of at least one prescription a medical care event due to medication error with error with QC discharge information. certain,probableorpossiblecausality.Thiswascompared In a second study, primary care physicians and munici- to 16 out of 179 patients (8.9%) in the control arm (C) pality care nurses were asked how much time theyspend recruited retrospectively from the same departments, an checking correctness of a patient’s medication list when absoluteriskreductionof4.5%(p=0.049).Afurtherana- they were discharged from hospital to municipality lysis of the data revealed that these medical care events care.27 The survey was based on two scenarios with and wereeitheroutpatientcontacts(I:10;C:13)orhospitalisa- without an LIMM-discharge information. The average tions (I:1; C:3), none of them statistically significant timeallocatedbyamunicipalitycarenursewasestimated (table1).Thesplitbetweenunscheduledoutpatientvisits to 59min for patients discharged without a medication (42%) and telephone contacts (58%) due to medication report.27Forthosepatientsdischargedwithamedication errors were taken from observational data among 100 report, the average time for a nurse was 26min when random patients aged 54 and above from March 2006 to inconsistencies between previous medication and the November 2006 (Lina Hellström; data on file). In add- mediation report was found (89%) and 3min when no ition, we assumed that a telephone contact and a visit inconsistencieswerefound(11%)(table1). would consume 15 and 30min, respectively, in physician In the event the primary care physician had to be con- time including medical chart updating (Patrik Midlöv, tactedtocorrectinconsistencies,(s)hewouldhavetodevote personalcommunication). a certain time to review the medication list and perhaps The probability of a medication error with and contact the discharging physician at the hospital clinic. It without the intervention has been estimated to 32% and was estimated that primary physicians spent on average 66%, respectively.21 However, in order not to double 14.8minforreviewingthemedicationlistand4.9minifthe count the cases which had to seek medical care due to discharging physician at the hospital clinic had to be con- medication error, we subtracted these events resulting in tacted.27Thecorrespondingtimeintheinterventiongroup 31.5% and 62% (p<0.001) patients with at least one wasestimatedtobe4.7and2.3min,respectively. medication error in the intervention arm and the control arm, respectively. With the introduction of Unit costs and dis-utilities quality-controlled (QC) discharge information, the Costs for hospital re-admissions in Part 1 were collected number of patients with at least one medication error from the hospital accounting database, but revealed no was reduced from 36.5% to 26.9% (p=0.278; RR=0.737) statistically significant difference in means between the in a study performed at Landskrona Hospital with 115 study arms (table 1). The same hospitalisation cost was GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 3 Health economic evaluation of the LIMM model Table1 Modelinputs:probabilities,costs(Euro2009),utilityanddistributions Distribution Mean SD Admissionpart:medicationreconciliationandreviewprocessatinitialhospitaladmission Probabilityofdeathbeforedischarge Control β 0.089 0.029 Intervention β 0.110 0.031 Probabilityofdeathduring3monthafterdischarge Control β 0.098 0.030 Intervention β 0.093 0.029 Probabilityofhospitalreadmissions Control β 0.130 0.034 Intervention β 0.062 0.024 Meanhospitalcostperhospitalisedpatient Control(sensitivity) γ 3620 2843 Intervention(sensitivity) γ 4925 3352 All18hospitalisations γ 4055 2989 Drugreviewcostperpatient Control γ 45.57 23.36 Intervention γ 33.92 14.24 Dischargepart:medicationreportatdischargefromhospital Probabilityofhospitalreadmissions Control β 0.017 0.013 Intervention β 0.004 0.006 Probabilityofunscheduledoutpatientcontact Control β 0.073 0.026 Intervention β 0.040 0.020 Probabilityofprescriptionerror Control β 0.620 0.487 Intervention β 0.315 0.465 RelativeriskreductionforprescriptionerrorprobabilitywQC 0.737 Outpatientnursingtimecostforreviewofmedicationlist Control γ 25.65 10.77 Intervention γ 10.21 4.29 Primaryphysician-patientcontactcost Botharms γ 18.58 9.19 Primaryphysician-nurse/dischargingcliniccontactcost Control:physician-nurse γ 12.86 5.53 Control:physician-clinic γ 4.29 0.62 Intervention:physician-nurse γ 4.05 3.15 Intervention:physician-clinic γ 1.99 0.51 Interventioncost Traininginmedicationreportcost γ 0.35 0.07 QCofdischargeinformation γ 8.70 3.65 Utilitydecrement (assumption) Forhospitalisations β 0.060 0.085 Foroutpatientcontact β 0.002 0.001 QC,qualitycheck. applied in both the Admission and Discharge parts. The Utility decrements,in terms of QALY due to rehospita- physician’s, pharmacist’s and nurse’s time were costed at lisations in parts 1 and 2, were taken from the literature €0.87, €0.52 and €0.43/min, respectively, including and a weighted mean was calculated for the main rehos- payroll-taxes (42%) and overhead costs (25%). pitalisation diagnoses from Part 1 (atrial fibrillation, Intervention costs include both pharmacist’s and physi- hypoglycaemia, chronic obstructive pulmonary disease, cian’s time for review, communication, prescription, hip fracture, heart failure).28–32 For patients experien- training and quality checks. As we did not have informa- cing a medication-related healthcare contact, we tion on the variability in nurse costs, we assumed the SD assumed a disutility decrement of 0.0014 QALY for a to be 42% of the mean, which was the average coeffi- telephone contact, corresponding to approximately cientof variation for the othercost items in Part 2. 2.5days with moderate pain or discomfort according to 4 GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 Health economic evaluation of the LIMM model the UK EQ-5D tariff.33 For a primary care visit, we pay. However, owing to space restrictions, they were not assumed a decrement of0.0028. presented graphically. Sensitivityanalysis RESULTS In the base case scenario, all variables are set according The first part of the model, that is, the systematic medi- totable 1 with aprobabilisticsensitivityanalysis following the specified distributions and parameter values. In cation reconciliation and review process at initial hos- pital admission (Admission part), estimated the total order to test the sensitivity of the results to some of the cost for the intervention arm to €260 including the cost variables, weperformed the followinganalyses: ▸ No quality control of the medication report at dis- for pharmacist time of €34 (table 2). This was €273 lower than in the non-intervention group, which, chargefrom hospital; ▸ Hospitalisation cost reduced to 50%; together with 0.004 QALYs gained, indicated that the ▸ Hospitalisation cost 36% higher in intervention arm; medication reconciliation and review process was a dom- ▸ Admission part probability for hospitalisation in inter- inant alternative, that is, both cost saving and producing more health. As this intervention mainly affected the vention arm +100%; ▸ Intervention cost (time) 50% higher; probability of unplanned rehospitalisations and out- ▸ Cost (time) for physicians and nurses administration patient visits, almost all cost savings arose in this cost item (€262). The drug review cost in the Standard Care reduced to 50% and ▸ Everyanalysis was performed with 10000 iterations. arm (€46) was mainly a result of more costly physician time devoted to medication reconciliation upon discharge. Presentation The second part analysed the quality-controlled medi- Costs (Euro) and effects (QALY) are presented as cation report at discharge from hospital (Discharge means and SEs for both the standard procedure and the part). Also this intervention was dominant as it gener- intervention arms. We also present scatterplots with all ated cost savings of €66 and improving health, although 10000 iterations in the cost-effectiveness plane from the only marginally (0.001 QALYs gained). The intervention PSA, that is, the incremental cost (y-axis) is paired with cost was lower as the time allocated for training in medi- the incremental effect (x-axis) from each iteration. In cation reporting and quality control was much shorter addition, cost-effectiveness acceptability curves were cal- than in the Admission part. The savings in terms of culated for different willingness to pay thresholds.34 avoided rehospitalisations and outpatient visits (€48) was These present the probability that the additional cost of lower than in the Admission part as a result of the lower the intervention per QALY gained, compared with probabilities for these events to occur. The cost savings routine procedure, is less than the chosen willingness to for ‘Primary care nurse/physician administration cost’ Table2 BasecaseresultsoftheLIMMprocessversusstandardcare(costsinEuro) LIMM Standardcare Difference Mean SE Mean SE Mean SE Drugreviewcost Admission 34 14 46 24 −12 28 Discharge 5 2 0 0 5 2 Subtotal 39 14 46 24 −7 28 Primarycarenurse/physicianadministrationcost Admission 0 0 0 0 0 0 Discharge 10 4 33 10 −23 11 Subtotal 10 4 33 10 −23 11 OPvisitandhospitalstaycost Admission 226 200 488 396 −262 278 Discharge 15 21 63 63 −48 58 Subtotal 241 209 551 440 −310 308 Grandtotalcost Admission 260 200 534 397 −273 280 Discharge 30 21 96 64 −66 59 Total 290 210 630 441 −340 310 QALYloss Admission 0.003 0.005 0.007 0.011 −0.004 0.007 Discharge 0.000 0.000 0.002 0.002 −0.001 0.001 Total 0.004 0.005 0.009 0.011 −0.005 0.007 Incrementalcost-utilityratio Admission Dominant Discharge Dominant Total Dominant LIMM,LundIntegratedMedicinesManagement;OP,outpatient;QALY,quality-adjustedlife-year. Dominant,costsavingandgreaterutilitywiththeLIMMmodel. GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 5 Health economic evaluation of the LIMM model Figure2 Scatterplotinthecost effectivenessplanefortheLund IntegratedMedicines Managementprocess. (€23) was mainly driven by the time the outpatient Sensitivityanalyses nurse had to devote to review and update the medical The sensitivity analysis indicated that the results were list for the patient at the community level. robust to several changes (table 3). As we ran probabilis- In total, the integrated process could be expected to tic sensitivity analysis costs and effects in both the inter- generate savings of €340, in spite of an intervention cost vention and the control, arms can change relative to the of €39, and gained utility of 0.005. The main savings base case scenario. These differences from the base case accrued from the systematic medication reconciliation were thereforedue to probabilistic differences. and review process at initial hospital admission If no quality control of the medication list at discharge (Admission part) owing to the reduced probability of was performed, the potential cost savings increased mar- unplanned rehospitalisations. ginally. As these medication errors did not result in any Hence, because of the cost saving and the increased substantial medical care contacts, the reduced interven- utility, the probability that the intervention would be tion cost for quality control (€4.9) was greater than the cost-effective at a zerowillingnessto pay fora QALY gain expected increase in medical list review cost for nurse would be 98%. This means that the intervention is and/or physician due to medication errors (€0.56). As expected to be cost-saving at a 98% chance in spite of we only accounted for any disutility in connection to the underlying uncertainty in the parameter values. medical care, the quality control did not affect the However, as some observations from the PSAwere found resulting utilities. in the north-west quadrant (figure 2), where the inter- As the main cost off-set was seen in avoided hospital- vention was more costly and resulted in a worse isation, we would expect the results to be sensitive to outcome, the probability that the intervention would be changes in this cost. When this cost was reduced to 50% 100% cost effectivewas not possible. for both treatment alternatives, the net cost savings Table3 Sensitivityanalysis(Euro) QALY Costs gain Cost-effectiveness Analysis Intervention Control Difference at€0WTP(%) Basecase 290 630 −340 0.005 98 Noqualitycontrolofmedicationlistatdischarge 284 626 −342 0.005 98 Hospitalisationcost50% 170 356 −185 0.005 98 Hospitalisationcost36%higherininterventionarm 339 567 −228 0.005 69 Admissionpartprobabilityforhospitalisationin 484 619 −135 0.002 80 interventionarm+100% Interventiontime+50% 309 629 −320 0.005 97 Reviewtimeforphysicianandnurse−50% 377 578 −301 0.005 96 QALY,QALY,quality-adjustedlife-year;WTP,willingnesstopayforagainedQALY. 6 GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 Health economic evaluation of the LIMM model almost halved (€185). In the base case, we used a cost decreased level of care in the control group than before per hospitalisation that was equal in both arms due to introducing the intervention. There is a need for higher small number of observations. When costs were split in attention and further studies inthis field. separate costs for patients in the control arm (€3620) The time utilisation in primary and municipality care and the intervention arm (€4925), or 36% higher, the for calculating administrative costs for error corrections scope for cost savings fell to €228. Likewise, when the was also based on surveys.27 In addition, utilities were probability of hospitalisation in the Admission part was taken from the literature and may not entirely reflect doubled, the potential savings fell to €135, or by 60%. In the analysed patient population. This are, of course, addition, as a consequence of the increased probability weaknesses in this study, but nevertheless, the resulting inhospitalisation, the resulting utility gain was reduced. cost savings were shown to be stable in spite of several Increasing the intervention time by 50%, that is, the sensitivity analyses which indicated that these shortcom- time for pharmacists in the reconciliation at hospital ings may be of less importance. Hence, discarding the admission and quality control of medication lists at dis- assumed utilities, the model would still be valid for a charge, reduced the potential savings marginally to cost-minimisation analysis. €320. Reducing the labour cost, that is, the time physi- Apart from just estimating the costs and effects from cians and nurses spent on reviewing medication lists by the two main studies, we also modelled the conse- 50%, had of course a greater consequence in the quences of quality-controlled medication lists. The control arm as the time they devoted for this task was effects from this control may have been conservatively greater than in the intervention arm. Still, the results estimated asthe reduction in errors was assumed to only had only a very small impact on the cost savings com- reduce the time devoted to correct these errors. One pared tothe basecase (−11%). could argue that some of these avoided errors could have had an impact also on the probabilities of unplanned rehospitalisations and outpatient visits. DISCUSSION However, the potential gain from these unplanned Combining the medication reconciliation and review healthcare contacts in the Discharge part would be process at initial hospital admission (Admission part) limited to less than €17 in the intervention arm. with a quality-controlled medication report at discharge However, the benefit from the LIMM-discharge part has from hospital (Discharge part) was shown to generate probably been improved since the initial study per- both cost savings and higher utility to the patients. In formed in 2005.21 The medication report is now part of fact, investing €39 in clinical pharmacist time could save the LIMM-discharge information and this have been €340 in medical care at hospital and in primary care, as shown to improve time-utilisation for general practi- well as in administrative costs for correcting errors in tioners and community carenurses.26 27 medication lists in primary and municipality care after Aspreviously described,severalstudies present positive discharge. Furthermore, the analysis showed that the economic benefits from clinical pharmacy services potential for cost off-set was greatest for systematic medi- study.15Bojkeetalperformed ahealtheconomicanalysis cation reconciliation and review process at initial hos- on the RESPECT trial (Randomised Evaluation of pital admission due toavoided costly hospitalisations. Shared Prescribing for Elderly people in the Community The main data sources supporting the probabilities over Time) which included services similar to our for unplanned rehospitalisations, outpatient visits and study.15 The RESPCT trial measured both resource use prescription errors were based on two studies.6 21 One and utility of the patients but did not attain statistically of the studies was a controlled pre–post study and the significant differences in outcomes. Their intervention outcome was assessed blind.6 In a recent systematic was expected to cost an extra £192 per patient and year review of hospital-based medication reconciliation prac- with a gain of 0.019 QALY, resulting in an incremental tice, this study was evaluated as a non-controlled pre– cost-utility ratio of approximately £10000 (2004–2005 post study and was consequently erroneous evaluated as prices). Apart from differences in healthcare structures being of poor quality.35 However, it must be stated that between the UK and Sweden, the discrepancy in results some of the reported resource utilisation (costs) did not may be attributable to the fact that the RESPECT trial show statistically significant differences between the was a primary care-based pharmaceutical care interven- treatment arms for example, the hospitalisation cost. tion whereasthe LIMM processwas hospital based. Small patient samples and great variability in the studied A recent Swedish study providing similar services as in variable is often the reason for this. All bias and con- LIMMconcludedthatahospital-basedclinicalpharmacist founders could not be ruled out since the studies were wasnotcosteffectiveaccordingtotheSwedishwillingness not randomised and controlled for. However, in our to pay for a gained QALY.16 In fact, the cost in the inter- opinion patient-based randomisation could be problem- ventionarmtendedtobehigherthaninthecontrolarm, atic in team-based interventions. There is of course a and with only marginal QALY-gains. The authors discuss risk of bias due to carry over effects decreasing the dif- some potential reasons for this outcome, eg, the use of ference between groups. But there is also a risk of bias inexperiencedpharmacists.IntheLIMMmodel,thephar- increasing the difference between groups owing to a macists werefully integrated inthecare team and worked GhatnekarO,BondessonÅ,PerssonU,etal.BMJOpen2013;3:e001563.doi:10.1136/bmjopen-2012-001563 7 Health economic evaluation of the LIMM model verystructuredandsystematic.Thedifferencebetweenthe among elderly patients, foremost due to avoided studies’ results could therefore describe a learning curve drug-related hospital readmissions. As the number of and or the benefit of a trustful care team supporting the elderly increase in most western countries, the scope for patient. Furthermore, ourcost analysis included only hos- saving resources within the healthcare sector can there- pitalisations that were considered drug-related during a fore be rather substantial. However, when implementing 3-month period after discharge whereas Wallerstedt et al such a review process with a multidisciplinary team, it included all hospitalisations during 6months. When may be important to consider a structured use of check- including probabilities only for drug-related hospitalisa- lists, as well as a learning curve, in order to capture the tions, we avoided hospitalisations due to differences in fulladvantage. patient characteristics and comorbidities between the Contributors TEandÅBaretheleadinvestigatorsfortheLIMMmodel,have study arms. Still, historical controls’ medical records were fullaccesstodatafromthestudiesincludedintheanalysesandconceived scrutinised to identify ‘certain’, ‘probable’ or ‘possible’ theideaofthestudy.OGandUPwereresponsibleforthedesignofthe hospital readmissions, which may introduce bias from cost-utilitymodelandOGwasresponsibleforthedataanalysisandproduced thetablesandgraphs.TheinitialdraftofthemanuscriptwaspreparedbyOG eithertoostrictortoolooserulesforcausality. andTE.Allauthorsassistedinplanningthestudy,developingananalysis Hence, the size of the gains may not be permanent. plans,interpretingdataandcriticallyrevisedraftsofthemanuscript. In addition, one could argue that the cost effectiveness Funding ThisstudywasfundedbyApoteketFarmaciAB. may be reduced as more and more medication lists will eventually have been reviewed. However, the errors ana- Competinginterests TEwaspreviouslyheadofresearchanddevelopmentat ApoteketFarmaciAB.Thiscompanyisastate-ownedpharmacycompany lysed in the LIMM model are often generated during whichhadcommercialinterestindisseminatingtheLIMM-model. the hospital stay why we believe this process is important Provenanceandpeerreview Notcommissioned;externallypeerreviewed. to improve the care given and to save resources even in the future. Furthermore, the elderly part of the Swedish Datasharingstatement Noadditionaldataareavailable. population will increase and, hence, the disease burden. Thus, the scope for cost-savings may change with the REFERENCES development of the healthcare structure and internal 1. 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