Jeroen van de Pol

89 4 Cost-utility and cost-effectiveness analysis of a clinical medication review Introduction In most developed countries the number of older people with multimorbidity and chronic medication use is expected to continue to rise in the coming decades [1]. The chronic use of multiple drugs may lead to drug-related problems (DRPs) and inappropriate prescribing [2,3]. This may have a large impact on healthcare expenditure and is amajor challenge for the upcoming years [4-8]. To reduce DRPs and to prevent people from medication-related hospital admissions, guidelines recommend a regular review of medication use by clinical medication reviews (CMR) [9]. A CMR is ‘a structured critical examination of patient's medicines with the objective of reaching an agreement with the patient about treatment, optimizing the impact of medicines, minimizing the number of DRPs and reducing waste’ [10]. It has a multidisciplinary approach and the patient, physician and pharmacist are involved. There is abundant evidence on the effectiveness of CMRs regarding the reduction of DRPs. Moreover, several studies have shown positive effects on intermediate outcomes, such as LDL-cholesterol, HbA1c or hypertension. The evidence for effects on more clinically relevant outcomes, such as pain-scores, falls, hospital admissions, health-related quality of life (HR-QoL) and on cost savings is limited [11-19]. A CMR may reduce healthcare expenditures, but a CMR itself is labor intensive and could therefore contribute to a further rise in healthcare costs. For studies to measure the cost-effectiveness of CMR, they should ideally measure HR-QoL and estimate quality-adjusted life years (QALYs) [20]. However, many interventions that are performed during CMR are unlikely to improve HR-QoL for the short term (e.g. starting statins or acetylsalicylic acid as primary or secondary prevention will not increase HR QoL on a time horizon of six months). We expect that more specific attention to older patient's preferences, personal goals and complaints related to their health and medication during a CMR can potentially increase their HR-QoL. The ‘Drug use Reconsidered in the Elderly using goal Attainment scales during Medication Review’ (DREAMeR) study was designed based on these assumptions to assess the clinical and economic impact of a CMR for older persons ( ≥ 70 years) using at least seven drugs in primary care. The aim of this economic analysis is to perform a cost-utility and cost-effectiveness analysis from a societal perspective of this patient centered CMR focused on patient's preferences, personal goals and complaints, compared to usual care.