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How should we better measure the cost-effectiveness of deprescribing interventions? Recommendations for improving value assessment

Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: Suggestions for improvement [published online ahead of print, 2023 Feb 21]. J Am Geriatr Soc. 2023;10.1111/jgs.18298. doi:10.1111/jgs.18298

Despite the well-established link between deprescribing interventions and reduced use of potentially inappropriate medications (PIMs), there is little evidence behind the cost-effectiveness of these interventions. Eight members of the USDeN Junior Investigator Intensive (JII) program joined forces to publish a commentary on value assessment of deprescribing interventions, published in the Journal of American Geriatrics Society last month.

Authors provide an overview of cost-effectiveness analyses (CEAs), a standard approach to deprescribing value assessment. Most CEAs report value as cost per quality-adjusted life years (QALYs), while some report cost per PIM stopped or per increase in the medication appropriateness index. These approaches are limited by short time windows and their lack of relevance to a variety of patient-centered outcomes. Our JII members provide the following recommendations for value assessment:

Recommendation #1: Extend the Time Frame

Extending the window of time for CEAs would allow researchers to observe the impact of deprescribing on longer term risks. For instance, deprescribing a PIM today may reduce one’s risk of hospitalization several years from now. A longer time horizon would also provide insight into longer term clinical outcomes not observed over the standard 2–12-month timeframe of deprescribing CEAs.

Recommendation #2: Include the Health System Perspective

Previous deprescribing CEAs only include third-party payer and societal perspectives. Including the health system perspective would shed light on feasibility and acceptability of a deprescribing trial within a specific population or setting. Expected intervention success rate is one example of a contextual factor which can impact the value equation. CEAs could also include quality measures in value assessment, such as 30-day hospital readmission rate, as higher quality ratings achieved through deprescribing can benefit health systems by attracting patients and payors. Authors also recommend including a budget impact analysis to help payors and health systems decide whether they can afford the intervention.

Recommendation #3: Incorporate Patient-Centered Value

To avoid underestimating the impact of deprescribing interventions, CEAs should include quality-of-life indicators and report on outcomes most important to patients. For instance, CEAs could account for the psychological and pragmatic burden of multiple medications. Deprescribing interventions are now starting to include a validated, patient-reported outcome measure of medication-related burden quality-of-life (MRB-QoL) that could inform future QALY calculations. Lastly, value assessment should include alignment of the treatment plan with individual life goals, for example cost per patient receiving goal-concordant care.

Primary author and JII member Anna Hung PharmD, PhD, MS summarizes her hope for deprescribing CEAs moving forward:

Future CEAs of deprescribing interventions could consider incorporating additional patient-centric value elements. One example is the additional value to patients from reducing any burden and/or discomfort from taking too many medications (which older adults have reported). Another example is if a deprescribing intervention improved a patient’s ability to achieve his/her life goals, such as the cessation of a medication that was causing dizziness now allowing that patient to do what was important to him/her.

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