Supporting people taking medicines for chronic illness improves health and saves the NHS money

Elliott, Rachel (Corresponding participant)

Division of Population Health, Health Services Research & Primary Care (L5)

Impact: Health and wellbeing

Public summary

Initial work by Barber et al suggested that medicines adherence could be improved by intervening early after a patient was newly prescribed a medicine for a chronic condition, and this was used to design an intervention that was subsequently shown to be effective (Clifford et al 2006) and cost effective (Elliott et al 2008).•Intervention: pharmacist telephoned 2 weeks after new Rx for chronic illness to discuss medication•Patients: (N=394) Already on >3 medications: >74 or stroke, cardiovascular disease, asthma, diabetes, RAs •Results at 1 month follow-up: Self-reported non-adherence: 8% versus 16% p=0.030; medication related problems: 23% versus 34% p=0.019; Mean total patient costs (NHS): £77.8 versus £113.9 p<0.05.•86% probability that the intervention dominated standard practice. Published papers:•Clifford S, Barber N, Elliott RA, Hartley E, Horne, R. Patient-centred advice is effective in improving adherence to medicines. Pharmacy World and Science 2006; 28: 165-170. http://dx.doi.org/10.1007/s11096-006-9026-6•Elliott RA, Clifford S, Barber N, Hartley E, Horne R. The cost effectiveness of a pharmacy advisory service to improve adherence to medicines. Pharmacy World and Science 2008; 30: 17-23 http://dx.doi.org/10.1007/s11096-007-9134-yIn 2009 Elliott was requested to provide updated estimates of costs from the 2008 paper. This work was used as part of DH budget impact analysis (available as hard copy, scanned version attached to this document) to make the case for implementing the New Medicine Service (http://www.nhs.uk/nhsengland/aboutnhsservices/pharmacists/pages/medicine-service-qa.aspx).Via a competitive tender process, Elliott et al won the commission by PRP (DH) to evaluate the implementation of the NMS, to assess whether it was cost effective for the NHS to commission the service permanently through community pharmacies. The service was shown to be effective and cost-effective: NMS generated a mean of 0.06 (95%CI: 0.00, 0.16) more QALYs per patient, at a mean reduced cost of -£190 (95%CI: -929, 87). NMS dominates current practice, with an ICER (95% credibility range) of -£3 005 (-17 213, 4 543). The probability that NMS dominates current practice is 0.81. NMS has a high probability (0.97) of cost-effectiveness at a willingness-to-pay of £20 000 for one QALY. NMS increased health gain at a cost per QALY well below most accepted thresholds for technology implementation, usually about £20,000 to £30,000 in the UK. To put thee results into context, A 65 year old man (woman) with moderate hypertension and mild to moderate renal failure will gain 0.10 (0.06) QALYs from taking a statin (Kevin F. Erickson et al. Cost-Effectiveness of Statins for Primary Cardiovascular Prevention in Chronic Kidney Disease. J Am Coll Cardiol. 2013;61:1250-8. doi:10.1016/j.jacc.2012.12.034), demonstrating that NMS confers the same benefit as statins. Published papers:•Matthew Boyd, Justin Waring, Nick Barber, Rajnikant Mehta, Antony Chuter, Anthony J Avery, Nde-Eshimuni Salema, James Davies, Asam Latif, Lukasz Tanajewski, Rachel A Elliott*. Protocol for the NMS Study: a randomised controlled trial and economic evaluation comparing the effectiveness and cost effectiveness of the New Medicines Service in community pharmacies in England. Trials.2013, 14:411. DOI: 10.1186/1745-6215-14-411 •Rachel A Elliott, Matthew Boyd, Justin Waring, Nick Barber, Rajnikant Mehta, Antony Chuter, Anthony J Avery, Lukasz Tanajewski, James Davies, Nde-Eshimuni Salema, Asam Latif, Georgios Gkountouras, Christopher Craig, Deborah Watmough. Department of Health Policy Research Programme Project ‘Understanding and Appraising the New Medicines Service in the NHS in England (029/0124)’ A randomised controlled trial and economic evaluation with qualitative appraisal comparing the effectiveness and cost effectiveness of the New Medicine Service in community pharmacies in England. 14th August 2014, www.nmsevaluation.org.uk. •Justin Waring, Asam Latif; Matthew Boyd; Nick Barber; Rachel Elliott. Pastoral power in the community pharmacy: a Foucauldian analysis of services to promote patient adherence to new medicine use. Social Science and Medicine 04/12/15. http://www.sciencedirect.com/science/article/pii/S0277953615302550 DOI: 10.1016/j.socscimed.2015.11.049 •Asam Latif, Justin Waring; Deborah Watmough; Nick Barber; Chuter Antony; James Davis; Salema Nde-Eshimuni ; Matthew J Boyd; Rachel A Elliott. Implementing complex health care interventions in community pharmacy: Qualitative analysis of the organisation and delivery of the English community pharmacy New Medicine Service (NMS) Research in Social & Administrative Pharmacy 2015 doi:10.1016/j.sapharm.2015.12.007.•Brinkmann L, Elliott RA, Tanajewski L. An economic evaluation to assess the cost effectiveness of the new medicine service in improving adherence in people initiated on new treatment for gout. Value Health. 2015 Nov;18(7):A650. doi: 10.1016/j.jval.2015.09.2338•Elliott RA, Tanajewski L, Gkountouras G, Boyd MJ, Barber N, Mehta R, Anthony J Avery, Asam Latif, Antony Chuter, Justin Waring. Cost Effectiveness of Support for People Starting a New Medication for a Long-Term Condition Through Community Pharmacies: An Economic Evaluation of the New Medicine Service (NMS) Compared with Normal Practice. Pharmacoeconomics July 2017. DOI: 10.1007/s40273-017-0554-9 •Latif A, Waring, J., Watmough, D., Boyd, M. J. & Elliott, R. A. “I expected just to walk in, get my tablets and then walk out”: on framing new community pharmacy services. Sociology of Health and Illness. Accepted February 2018.SIGNIFICANCE:Improvement in health at reduced overall cost in managing chronic illness. Inverse care law, equity of access, SEG gradient for many of the diseasesOther commentsIt is unusual to have such a clear trail from evidence to policy development, then to further research impacting on national commissioning decisions. This is also one of very few community pharmacy interventions to be so strongly evidence-based. During the research period, there was a general sense of concern about the outcome of the study, as there was a perception in the profession and DH and this type of evidence was pivotal in underpinning further developments in the “non-supply” or clinical role of community pharmacy. Therefore, this has already had significant national reach and impact, along with interest from other countries also looking to provide evidence-based primary care.

NMS IMPLEMENTATION (England)

· Expanded to other conditions. From 1st September 2021, the following conditions are covered by the service: https://psnc.org.uk/national-pharmacy-services/advanced-services/nms/

o Asthma and COPD:

o Diabetes (Type 2);

o Hypertension;

o Hypercholesterolaemia;

o Osteoporosis;

o Gout;

o Glaucoma;

o Epilepsy;

o Parkinson’s disease;

o Urinary incontinence/retention;

o Heart failure;

o Acute coronary syndromes;

o Atrial fibrillation;

o Long term risks of venous thromboembolism/embolism;

o Stroke / transient ischemic attack; and

o Coronary heart disease

o The antiplatelet/anticoagulant therapy eligibility continues, but it is now included in the above list by reference to the underlying condition/reason for prescribing.

· 2023 plan to include depression: https://psnc.org.uk/national-pharmacy-services/advanced-services/nms/

OTHER COUNTRIES

· Denmark¹

· Norway²

· Spanish NMS RCT protocol:³

· South Africa⁴

· Poland⁵

· Review Reimbursed medication adherence enhancing interventions in 12 European countries (doesn’t include English NMS studies, so probably flawed search strategy)⁶

· Call for research in adherence (doesn’t include any English adherence or NMS studies, so probably flawed search strategy)⁷

UPDATES REFERENCES

1. Kaae S, Dam P, Rossing C. Evaluation of a pharmacy service helping patients to get a good start in taking their new medications for chronic diseases. Research in Social and Administrative Pharmacy2016;12(3):486-95. doi: https://doi.org/10.1016/j.sapharm.2015.08.002

2. Bremer S, Henjum S, Sæther EM, et al. Drug-related problems and satisfaction among patients receiving pharmacist-led consultations at the initiation of cardiovascular drugs. Research in social & administrative pharmacy : RSAP 2022;18(11):3939-47. doi: 10.1016/j.sapharm.2022.06.005 [published Online First: 2022/06/25]

3. Vera; MdlAG, Cabrera; MdCV, Narbona; JL, et al. Effect of an intervention New Medicine Service to improve adherence in the Spanish community pharmacies: a protocol of a pragmatic randomised trial. Ars Pharmaceutica (Internet) 2022 doi: 10.30827/ars.v63i3.24625

4. Naidoo V, Moodley R, Bangalee V, et al. New Medicine Service by Community Pharmacists: An Opportunity to Enhance Universal Health Coverage at a Primary Health Level in South Africa. Inquiry2023;60:469580221146834. doi: 10.1177/00469580221146834 [published Online First: 2023/01/11]

5. Merks P, Chełstowska B, Religioni U, et al. Enhancing Patient Adherence to Newly-Prescribed Medicine for Chronic Diseases: A Comprehensive Review and Cost-Effective Approach to Implementing the New Medicine Service in Community Pharmacies in Poland. Med Sci Monit 2024;30:e942923. doi: 10.12659/msm.942923 [published Online First: 2024/03/03]

6. Kardas P, Bago M, Barnestein-Fonseca P, et al. Reimbursed medication adherence enhancing interventions in 12 european countries: Current state of the art and future challenges. Front Pharmacol 2022;13 doi: 10.3389/fphar.2022.944829

7. Kardas P, Ágh T, Dima A, et al. Half a Century of Fragmented Research on Deviations from Advised Therapies: Is This a Good Time to Call for Multidisciplinary Medication Adherence Research Centres of Excellence? Pharmaceutics 2023; 15(3).

Category of impact	Health and wellbeing
Impact level	Undefined