RPS disputes NICE appraisal of pharmacist medication reviews

The Royal Pharmaceutical Society (RPS) has disputed a proposed guideline from the National Institute for Health and Care Excellence (NICE) that says pharmacist-led medication reviews are “not cost effective” for the health service.

The economic assessment, outlined in a draft clinical guideline on medicines optimisation, is not in line with evidence of the benefits to patients seen in current pharmacy practice, the RPS said.

The Society also warned that the way the draft guideline was constructed meant it would have little impact on improving medicines optimisation in the NHS.

NICE recently ran a stakeholder consultation on its draft clinical guideline on medicines optimisation, which runs to 212 pages. It includes 49 recommendations that aim to guide the NHS on how to improve the safe and effective use of medicines and achieve better outcomes.

The recommendations encourage the use of medication reviews in cases of polypharmacy, among people with chronic conditions, and in older people. The reviews may be led by a pharmacist or another appropriate health professional, the guideline said.

However, the guideline’s economic evidence review found pharmacist-led medication reviews are not cost effective, with an at incremental cost effectiveness ratio (ICER) above £50,000 per quality-adjusted life year, compared with no intervention. This was based on two relevant studies identified by the evidence review, and is well above the £20,000–£30,000 per QALY level usually considered by NICE to be value for money for the NHS.

An assessment of three further studies found pharmacist medication reviews incurred extra costs overall compared with no intervention, while only one study found them to be cost saving.

The analysis found only a limited number of relevant studies to assess, and the guideline developers did not identify any evidence to inform the cost effectiveness of medication reviews undertaken by other health professionals.

In its consultation response, the RPS said: “The evidence review conclusion that medication review is not cost effective does not align with current practice.”

It said the conclusion was “at odds” with the guideline development group’s comments about the benefits of the reviews. It added: “The RPS believes that more research is needed into the growing evidence base around the benefits of pharmacist medication reviews. There is much activity around improving patient care, outcomes and safety in the UK, with over 100 examples in the ‘Now or Never: Shaping Pharmacy for the Future’ report, most of which deliver improved patient care and outcomes through integration of pharmacists into primary and secondary care teams.”

The Society added that the guideline “needs to be contextualised into the real-world setting if we are to realise the full potential of the evidence review”.

Elizabeth Butterfield, lead for medicines optimisation at the English Pharmacy Board (EPB), says: “We are not convinced that the guidance in its current format will have an impact on the implementation of medicines management in the NHS. We also think that the guidance is too long and complicated.”

Butterfield says the RPS had examples of medicines optimisation in practice and the difference this has made to patient outcomes and financial savings over time, and that these should be considered by NICE.

She adds that NICE’s decision not to address medicines adherence in the guideline would undermine its impact. “Medicines optimisation is about a change of focus from systems and process to putting the patient at the centre. Medicines adherence is a critical part of this.”

EPB chairman David Branford says: “Every health professional associated with medicines wants to see best outcomes from medicines for their patients and we as pharmacists want to play the key part in that either directly or as a part of the healthcare team.”

He says NICE’s guideline should refocus on “why we really need to do this; why current care results in the elderly and other vulnerable groups receiving many unnecessary medicines; why the current care fails so many people, the huge waste and why medicines optimisation is utterly essential”.

“Then it could move on to look at each of the components and guide us as to which are likely to deliver the most improvement for our bucks,” he adds. “Just reiterating existing guidance from other sources just makes the whole document too long and lacking focus.”

A NICE spokesman said its guideline development group will consider the points raised in the RPS response but that it would not comment further until publication of the final guideline, expected in March 2015.