Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling
Background: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. Objective: To evaluate the evidence of the clinical effe...
| Main Authors: | , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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NIHR Journals Library
2017-12-01
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| Series: | Health Technology Assessment |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/hta21780 |
| _version_ | 1818477952955842560 |
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| author | Céline Miani Adam Martin Josephine Exley Brett Doble Ed Wilson Rupert Payne Anthony Avery Catherine Meads Anne Kirtley Molly Morgan Jones Sarah King |
| author_facet | Céline Miani Adam Martin Josephine Exley Brett Doble Ed Wilson Rupert Payne Anthony Avery Catherine Meads Anne Kirtley Molly Morgan Jones Sarah King |
| author_sort | Céline Miani |
| collection | DOAJ |
| description | Background: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. Objective: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. Design/data sources: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. Review methods: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. Results: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference –0.45, 95% confidence interval –0.65 to –0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. Limitations: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. Conclusions: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. Future work: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. Study registration: This study is registered as PROSPERO CRD42015027042. Funding: The National Institute for Health Research Health Technology Assessment programme. |
| first_indexed | 2024-12-10T09:42:34Z |
| format | Article |
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| institution | Directory Open Access Journal |
| issn | 1366-5278 2046-4924 |
| language | English |
| last_indexed | 2024-12-10T09:42:34Z |
| publishDate | 2017-12-01 |
| publisher | NIHR Journals Library |
| record_format | Article |
| series | Health Technology Assessment |
| spelling | doaj.art-bb5a0e78dd51483393d69e5b17bb127a2022-12-22T01:53:58ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242017-12-01217810.3310/hta2178014/159/07Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modellingCéline Miani0Adam Martin1Josephine Exley2Brett Doble3Ed Wilson4Rupert Payne5Anthony Avery6Catherine Meads7Anne Kirtley8Molly Morgan Jones9Sarah King10Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Centre for Health Services Research, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UKCambridge Centre for Health Services Research, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UKCentre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UKSchool of Medicine, University of Nottingham, Nottingham, UKCambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Centre for Health Services Research, RAND Europe, Cambridge, UKCambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UKBackground: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. Objective: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. Design/data sources: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. Review methods: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. Results: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference –0.45, 95% confidence interval –0.65 to –0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. Limitations: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. Conclusions: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. Future work: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. Study registration: This study is registered as PROSPERO CRD42015027042. Funding: The National Institute for Health Research Health Technology Assessment programme.https://doi.org/10.3310/hta21780prescriptionchronic conditionslong-term conditionssystematic reviewprimary careeconomic analysiscprdmodellingeffectivenesscost-effectiveness |
| spellingShingle | Céline Miani Adam Martin Josephine Exley Brett Doble Ed Wilson Rupert Payne Anthony Avery Catherine Meads Anne Kirtley Molly Morgan Jones Sarah King Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling Health Technology Assessment prescription chronic conditions long-term conditions systematic review primary care economic analysis cprd modelling effectiveness cost-effectiveness |
| title | Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling |
| title_full | Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling |
| title_fullStr | Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling |
| title_full_unstemmed | Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling |
| title_short | Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling |
| title_sort | clinical effectiveness and cost effectiveness of issuing longer versus shorter duration 3 month vs 28 day prescriptions in patients with chronic conditions systematic review and economic modelling |
| topic | prescription chronic conditions long-term conditions systematic review primary care economic analysis cprd modelling effectiveness cost-effectiveness |
| url | https://doi.org/10.3310/hta21780 |
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