Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension
- Pharmacist prescribing interventions to improve BP control resulted in significant cost savings over a 30-year time horizon.
- The model expanded to the population level with a 50% uptake of pharmacist prescribing interventions would save over $1 trillion and 30.2 million patient life-years over 30 years.
Is pharmacist-managed hypertension in the United States cost-effective?
A Markov pharmacoeconomic model of patients with uncontrolled hypertension and no additional history of cardiovascular disease (CVD) or kidney disease was developed using Microsoft Excel. The model assumed that pharmacist-prescribing interventions would reduce blood pressure (BP), thereby resulting in a decreased risk of CVD and kidney disease.
The costs of pharmacist-managed hypertension were compared to long-term cost offsets as well as mortality benefits resulting in BP reductions. A mean systolic BP (SBP) reduction (-18.3 mm Hg) observed with the pharmacist-intervention arm in the RxACTION study was utilized for the base case, while the BP for the comparator group was assumed to remain at baseline levels. The CVD risk over time was calculated using Framingham risk equations for myocardial infarction, stroke, heart failure, and angina. The association between SBP reduction and reduced risk of CVD was estimated using results from the Blood Pressure Lowering Treatment Trialists’ Collaboration. The impact of BP on kidney disease was based on a reported association between BP and end-stage kidney disease (ESKD) incidence observed in a US historical cohort and a 25-year follow-up study. Mortality was based on US life tables.
For costs, pharmacist assessments were each valued at $23.10 using the 2019 reimbursement rate for Current Procedural Terminology codes, and medication costs were estimated at $32.78/month based on the mean monthly medication costs for individuals with hypertension in the US. Pharmacist visits were assumed to occur monthly for the first 3 months, then quarterly, with six total visits in the first year and four annually thereafter. CV event costs were based on values from a US microsimulation model of hypertension screening strategies and ESKD cost was based on information from the US Renal Data System. One-way sensitivity analyses were used to examine the impact of variation in key inputs, and a 1,000-iteration probabilistic sensitivity analysis was conducted to reflect the impact of stochastic parameter on uncertainty in results. An uptake rate for the intervention was assumed to be 50%.
There were 248 patients enrolled in the RxACTION trial (mean [SD] age, 64 [12.5] years; 121 [49%] male; 41 [15%] current smokers; and 109 [48%] with diabetes). The mean (SD) baseline BP was 150/84 (13.9/11.5) mm Hg with 1.7 (1.2) antihypertensive medications per patient. The pharmacist intervention was found to reduce SBP significantly more than the active control group (-18.3 mm Hg vs. -11.8 mm Hg, p < 0.001).
In the current base case analysis over a 30-year time horizon, the pharmacist intervention was associated with 2,100 fewer CVD cases and eight fewer ESKD cases per 10,000 patients. Pharmacist intervention was also associated with 0.34 additional life-years and 0.62 additional quality-adjusted life-years. Additionally, the cost reduction from fewer CV events more than offset the cost of pharmacist visits, leading to an overall cost savings of $10,162 per person. Broadening the model to the population level, a 50% intervention uptake was associated with a $1.137 trillion cost savings and 30.2 million patient life-years saved over 30 years.
A pharmacist-prescribing intervention to improve BP control was found to be cost-effective, resulting in an estimated cost savings of $10,162 per person over a 30-year time horizon with cumulative population savings of more than a trillion dollars. Savings were largely attributed to fewer CV events due to improved BP control.
Pharmacist interventions have been shown to significantly improve BP control but the economic impact of widespread adoption of such interventions has been unclear. This analysis demonstrated the cost-effectiveness of pharmacist antihypertensive prescribing interventions by showing reductions in CV events due to improved BP control. Rising rates of hypertension-related mortality as well as shortages of primary care clinicians in the United States has heightened the urgency for broader implementation of pharmacist intervention to improve BP control. Implementation of pharmacist-prescribing interventions on a broader scale will require ongoing advancement in scope of practice legislation and eligibility for reimbursement through Centers for Medicare & Medicaid Services.
Keywords: Antihypertensive Agents, Cost-Benefit Analysis, Hypertension
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