Cost-Effectiveness Of Warfarin Medication Therapy Adherence Clinic Versus Usual Medical Clinic At Kuala Lumpur Hospital
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Date
2016-04
Authors
Thanimalai, Subramaniam
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Abstract
Systematic anticoagulation management clinic is now recommended to manage atrial fibrillation (AF) patients on chronic warfarin therapy. In Malaysia, the service is recently introduced as pharmacist managed Warfarin Medication Therapy Adherence Clinic (WMTAC) which is managed by the pharmacist with a physician advisory. The objective of the present study was to assess the cost effectiveness of anticoagulation clinic in comparison to usual medical clinic (UMC) which is managed by medical officers in Kuala Lumpur Hospital (KLH), a tertiary referral hospital in Malaysia. A six month retrospective cohort study comparing the two anticoagulation management models was conducted. Systematic random sampling was used to sample a total of 92 patients from each clinic. The mean percentages of time within therapeutic range (TTR) for the patients which is recommended in the 2013 Malaysian Clinical Practice Guidelines on the Prevention and Treatment of Venous Thromboembolism were used as effectiveness. The mean total cost of each clinic included four cost activities such as the cost of monitoring, clinic consultation and dispensing, drug and adverse event. The costs were estimated using the time-motion study for the INR within and outside the therapeutic range. A six monthly cycle Markov model from the provider perspective was used to simulate life time cost effectiveness. The base case analysis assumed a cohort of patients with AF, 57 years of age with comorbid illnesses. The transition probabilities of these clinics outcomes were obtained from a literature search. The model assumptions were that the outcomes probabilities were similar for both the clinics and between the
cycles. Future costs and effectiveness were discounted 3% to convert to present values. All costs were in Malaysian Ringgit (MYR) based on year 2007. Percentage of time in therapeutic range (TTR) was also significantly higher in WMTAC than those in UMC (66.1% vs. 48.3%; p < 0.001). Mean six months treatment cost was MYR 537.38 (SD = 352.39) for UMC and MYR 352.62 (SD = 180.21) for WMTAC, which was significantly higher (p < 0.001). Results of a 20-year period model showed that the mean cost of the WMTAC was MYR 5864.10 whereas the UMC cost was MYR 6550.96 and the life-years to be 6.15 and 6.17 years for UMC and WMTAC respectively. UMC was found to be dominated by the WMTAC for both intermediate and lifetime analysis. The sensitivity analysis showed that clinic treatment costs had a major impact on the cost-effectiveness analysis. If the cost of WMTAC increased by 50% or if the UMC cost dropped more than 25% of the current cost, the WMTAC would not be a dominant intervention. In conclusion, WMTAC is a more cost effective option than UMC in KLH. The WMTAC is cost-effective, as it is able to improve the percentage of time within therapeutic range and reduce the frequency of clinics visits and ward admissions. Maintaining the TTR above the gold standard of 70%, is important to ensure its’ effectiveness.
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The cost effectiveness of anticoagulation clinic , in comparison to usual medical clinic