Jeroen van de Pol

101 4 Cost-utility and cost-effectiveness analysis of a clinical medication review Utilization of secondary care or institutional care can be expensive (e.g. one admission to a hospital or care home leads to large increases in healthcare costs) and therefore can also increase interpatient variability. However, even when the variation of these costs was performed, conclusions about cost savings were not influenced. The mean estimated cost for a CMR in this study was €199, which is comparable to the costs of €185 determined in an earlier report [31] and to the budget impact analysis presented in the current Dutch multidisciplinary guideline, which estimated costs for CMR between €136 and €303 [9]. The average time spent by the pharmacists for the patient interview in our study (50 ± 18 minutes) was relatively high [31], but this can be explained by the patient-centered approach with extra attention to the personal preferences, goals and health-related complaints of the patients. The GP spent at least an average of 12 ± 8 minutes on the CMR in this study, but this reflects only the discussion of the care plan with the pharmacist. There could have been potential other actions performed by the GP resulting from the CMR, that have been performed under standard GP care. Nevertheless, the total costs of primary care were lower in the intervention group compared to the control group. In the current study, follow-up was limited to two moments, which is lower compared to the Spanish study. Increasing the number of follow-up moments could further increase the effectiveness of CMR, but would also increase costs associated it. Adequate training is needed to perform CMR, but most Dutch community pharmacists are already accredited to perform CMR. Therefore, training costs were not attributed to the total intervention costs. However, large implementation worldwide would also need budgets to train pharmacists to perform these patient-centered CMRs. Because of the ageing society, with a rising number of older people with multimorbidity and polypharmacy, attention to maintain older people's health and concomitant containment of healthcare costs is essential. Goal-oriented patient care may improve the management of multimorbidity and polypharmacy [43,44]. When we extrapolate the results of this study to the whole country, there are around 300,000 persons aged 70 years and older using seven or more chronic drugs [9]. If we were to deliver this intervention to all eligible patients, this would cost around €60 million for the intervention, but concomitantly would lead to healthcare cost savings of around €114 million, resulting in a net benefit of €54 million over a period of six months.