Economic evaluation of home medication review by community pharmacists (HMR-CP) for patients with type 2 diabetes mellitus (T2DM)

Figures & data

Figure 1. Distribution of 10,000 bootstrapped ICERs for analyses with or without imputations.

Figure 2. Markov Model. Abbreviations. T2DM, Type 2 diabetes mellitus; HMR-CP, Home medication review by community pharmacists.

Table 1. Baseline inputs for the model including ranges and distribution.

Variables	Base case value	Range for sensitivity analysis		Distribution for PSA	References
		Lower	Upper
CVD events and outcomes
RR of death after CHD event	2.820	1.850	4.280	LogNormal	Wannamethee et al.^30
RR of death after stroke event	2.300	2.000	2.700	LogNormal	Dennis et al.^31
RR of subsequent CHD events (or a second CHD event)	2.224	1.557	2.891	LogNormal	Haffner et al.^32, Ramsey et al.^12
RR of subsequent stroke events (or a second stroke event)	1.889	1.322	2.456	LogNormal	Haffner et al.^32; Ramsey et al.^12
Utilities for each health state in the Markov model
Well (HMR-CP group)	0.900	0.800	1.000	Beta	Mehmood et al.^7
Well (control group)	0.800	0.680	0.920	Beta	Mehmood et al.^7
CHD event	0.770	0.500	0.990	Beta	Gage et al.^51; Yu et al.^36
Stroke event	0.675	0.600	0.900	Beta	Lampe et al.^52; Yu et al.^36
Disutility value for CHD event^a	–0.055	–0.226	–0.017	Triangular	Brennan et al.^53; Clarke et al.^54
Disutility value for stroke event	–0.164	–0.590	–0.034	Triangular	Brennan et al.^53; Clarke et al.^54
Death	0	Not applicable	Not applicable	Not applicable	Not applicable
Cost and utilisation of medical services inputs
CVD events
CHD event^b	13,375.16	7,235.56	19,514.76	Gamma	Lee et al.^55
Stroke event^c	7,638.53	3,819.27	11,457.80	Gamma	Aznida et al.^56
Implementation of HMR-CP
6-month cost of intervention^d	121.45	115.89	127.08	Gamma	Mehmood et al.^7
Use of healthcare services
6-month drug costs in HMR-CP group	246.48	211.84	284.59	Gamma	Mehmood et al.^7
6-month drug costs in the control group	220.02	174.24	280.25	Gamma	Mehmood et al.^7

^a The disutility value for CHD event was obtained from those T2DM patients with myocardial infections.

^b The cost of managing the first CHD event was assumed the same as the subsequent events and took into consideration the mean hospitalisation cost of patients undergone PCI at a general hospital in Malaysia.

^c The cost of managing the first stroke event was assumed the same as the subsequent events and took into consideration the average cost of treating an acute ischaemic stroke (including both major and minor events) and follow-up (i.e. outpatient visits and rehabilitation sessions) at a teaching hospital in Malaysia.

^d Intervention cost included training workshop on HMR, HMR visit by community pharmacists and transportation fee to perform HMR.

Figure 3. Tornado diagram.

Table 2. Intervention and health services costs throughout the 6-month HMR-CP trial.

Costs^a	Cost per patient (RM)						Cost difference per patient (RM)
	HMR-CP group			Control group			HMR-CP group vs control group
	Mean	95%CI		Mean	95%CI		Mean	95%CI
		2.5%	97.5%		2.5%	97.5%		2.5%	97.5%
Intervention costs^b
Training workshop on HMR^c	48.96	–	–	–	–	–	48.96	–	–
HMR visit by community pharmacists	48.81	44.35	52.74	–	–	–	48.81	44.35	52.74
Transportation fee to perform HMR	23.75	20.38	27.45	–	–	–	23.75	20.38	27.45
Subtotal	121.45	115.89	127.08	–	–	–	121.45	115.89	127.08
Health services costs
Monitoring tests (i.e. HbA1c, FBG)^c	34.00	–	–	34.00	–	–	0.00	0.00	0.00
Outpatient visit with family medicine consultant^c	360.00	–	–	360.00	–	–	0.00	0.00	0.00
Anti-diabetic medications	246.29	211.84	284.59	220.59	174.24	280.25	25.70	–42.32	86.62
Subtotal	640.14	605.37	678.04	614.10	567.84	672.51	26.26	–39.70	87.30

^a With imputation (bootstrapping).

^b Only incurred in the HMR-CP group.

^c Similar percentage of use for all patients in the groups.

Table 3. Cost and effectiveness outcome measures and intermediate ICERs.

	With imputation		Without imputation
	HMR-CP group	Control group	HMR-CP group	Control group
Cost
6-month (RM)	762.26	614.10	762.59	630.94
	(726.66 to 800.42)	(567.84 to 672.51)	(725.41 to 803.34)	(571.43 to 706.56)
Incremental cost	148.16		131.65
	(80.37 to 208.44)		(48.87 to 203.75)
Effectiveness
6-month (% HbA1c reduction)	0.910	0.008	1.018	−0.087
	(0.541 to 1.288)	(-0.346 to 0.374)	(0.627 to 1.415)	(-0.543 to 0.387)
Incremental effectiveness (% reduction of HbA1c)	0.902		1.105
	(0.388 to 1.412)		(0.481 to 1.716)
ICER
6-month (RM per reduction of HbA1c)	178.82		129.96
	(86.77 to 364.03)		(48.09 to 261.97)

Abbreviations. ICER, incremental cost-effectiveness ratio; HMR-CP, home medication review by community pharmacists; HbA_1c, glycated haemoglobin.

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