Cost analysis
This analysis assessed the costs of a community pharmacy to implement the program. Because it focused on the implementation costs from the provider’s perspective, patient and societal costs were not considered. We performed a micro-costing analysis that included three steps [37, 38]: (i) identifying the relevant activities necessary to implement, maintain and deliver the program, (ii) quantifying the required resources for each activity (e.g., labour, space, material), and (iii) valuing a unit cost for each resource. The analysis is presented in accordance with the project management tool: PERT chart (Program Evaluation and Review Technique) used to schedule, organize, and coordinate tasks within the project. The cost estimates were expressed in Swiss Francs (1 CHF = 0.88€ = $0.99, http://www.xe.com, 11/13/2018). The initial staff training and investment, as well as the equipment, were amortisable over a 5-year amortisation period.
Identification of activities & quantification of required resources
The identification of the relevant activities and the quantification of required resources were based on the experience of the Community Pharmacy of the PMU, University of Lausanne (Switzerland) [15]. The cost estimates were validated by consensus with two external community pharmacy owners established in the same Swiss canton (canton de Vaud) (JFL, CRO). Implementation costs occurring in the different phases of the implementation process (installation, initial and full operation phases) were differentiated by service support costs and direct service delivery costs according to the classification of Garcia-Cardenas et al. (2016) (see Fig. 1). Service support costs in the installation phase corresponded to start-up costs, required before the inclusion of the first patient.
Service support costs
Professional training: Pharmacist’s education
During the installation phase, the initial pharmacist training focused on (1) knowledge of medication adherence and (2) motivational interviewing skills. First, the pharmacist attended a 10-h adherence course organised into 5 modules: (i) introduction to medication adherence, (ii) theoretical frameworks of medication adherence, (iii) medication adherence interventions, (iv) structure of medication adherence interviews, and (v) case studies. Second, the pharmacist was trained in motivational interviewing during four 4-h sessions [15]. Then, during the initial and full operation phases, the pharmacist attended one day of continuous education per year, consisting of an update on medication adherence or motivational interviewing. For instance, at the Community Pharmacy Center of the PMU, a 1-h adherence internal meeting is organised every 6 to 8 weeks for educational purposes and for discussing complex case studies [15]. In the analysis, we considered the labour cost (i.e., time spent on training) and the course registration fee.
Professional training: Pharmacy technician’s training
In the analysis, we considered a day of internal training per each new pharmacy technician during the installation phase. The objectives were to train technicians on the handling of EMs, the secure uploading of EMs data and counting tablets. Moreover, during the initial and full operation phases, the technicians participated in the same education internal meetings along with the pharmacists. Initial training costs were amortised over 5 years.
Implementation strategies
In the installation phase, the pharmacist-technician duo needed two days to prepare and organise the delivery of the service. This time included the development of the planning process, the writing of procedures and the preparation of support material. To ensure the quality of the service and the fidelity in its delivery, the service is ISO certified at the Community Pharmacy Center of the PMU and all procedures are written and made available to the team at any time. The cost of support material was estimated by expert opinion, including patient leaflets and information and education material. In the initial and full operation phases, these efforts decreased but were still considered.
Equipment
According to Swiss law, a community pharmacy who offers a professional pharmacy service must have a privacy room or area that allows confidentiality for a face-to-face interview with the patient. Based on this fact, we assumed that pharmacists already had this space (including a computer) available for the medication adherence program, hence their acquisition costs were not considered in the analysis. As part of the equipment, we included the cost of the licence for a secure web platform to collect electronic patient data (i.e., SISPha®). This licence also comprises the implementation and technical support, including coaching meetings to guide the pharmacist during the interview and to edit the report for the physician and the nursing team (http://www.sispha.com). The cost of this annual licence was considered during all three phases of the implementation process.
Direct service delivery costs
The average duration of the follow-up per patient was estimated at one year in accordance with PMU data (median: 333 days; IQR25: 138; IQR75: 799) [15]. The frequency of interviews with the pharmacist depends on the patient’s needs, with a more intensive support activity at the beginning of follow-up. Hence, this analysis considered the theoretical frequency of interviews starting at once a month for the first three months and then once a trimester thereafter (associated with prescription refill). Accordingly, we estimated one inclusion and six follow-up visits per patient for the first year.
Workforce time
The variable costs associated with the delivery of the service included the pharmacist time (patient interviews, adherence report editing, collaboration with the physician) and the technician time (EMs handling). Since 2011, the Community Pharmacy Center of the PMU routinely collects all time, except for coordination. Thus, we used these established median durations [15]. However, because these data are self-reported and from a program in operation since 2004, they are affected by the professional’s experience and may also be underestimated. Therefore, in accordance with experts, we added 20% to the original PMU time data to more precisely estimate the real time needed for implementing the service in inexperienced community pharmacies. Additionally, we evaluated the time required for the coordination, including time spent on launching local networks between the pharmacist and the physicians and all interprofessional contacts during a patient follow-up (estimated by expert opinion).
Electronic monitoring
Health insurance in Switzerland effectively reimburses the medication adherence program for all polypharmacy patients, defined as people who are simultaneously prescribed at least three chronic treatments and who are referred by their physician to their pharmacist because of a history or a risk of poor adherence. Therefore, in this analysis, we decided to include the costs of three EMs per patient. The EM unit cost was annualised to consider a battery life of two years, including the cost of the hardware required to read EMs data.
Valuation of unit cost for each resource
Labour cost
The hourly labour costs for health professionals were estimated by expert opinion based on the Swiss salary scale in the canton of Vaud (http://www.vd.ch). This scale defines a salary level per profession (classes ranging from 1 to 18) according to professional experience (grades ranging from 0 to 26). The annual gross salary for a mid-career professional corresponded to class 11/grade 13 for a community pharmacist and class 4/grade 13 for a pharmacy technician. According to the finance department at the PMU, a multiplier coefficient (22%) was applied to consider social security contributions and reflect the full cost to the employer. Finally, the number of annual working hours used corresponded to the usual number of effective working hours in Switzerland (42 h30 per week excluding holidays, absenteeism and downtime).
Space cost
We considered the opportunity cost (i.e., the value of the resource in an alternative use) of the interview private room/confidentiality area used for the delivery of the service. To estimate the hourly cost of this space, the size of the room was fixed by expert opinion to ten square metres. The cost per square metre included the annual rent, maintenance and utility fees, derived from the annual cost survey on Swiss pharmacies in 2014 (“RoKA” report, http://www.pharmasuisse.org/de/). The total annual cost was divided by the mean opening hours in the canton (57 h per week in the “RoKA” report).
Break-even analysis (BEA)
The BEA formula can determine the volume of services (i.e., quantity, expressed in terms of the number of followed-up patients) needed to ensure that the generated revenues exceed the costs [36] (see Fig. 2). The “price” corresponded to the fixed total revenue per patient (i.e., the total fees charged by the pharmacist to the Swiss health insurances, depending on the number of chronic medications taken by the patient). In our case, it included a medication adherence support fee-for-service (21.60 CHF per week) and the sale of a pill organiser (18 CHF per quarter) per patient (http://www.pharmasuisse.org/de/). We estimated the break-even point using Microsoft Office Excel 2007 software.
Sensitivity analyses
Univariate sensitivity analyses were performed to assess the impact of the uncertainty generated by estimated parameters (other things being equal). This uncertainty takes into account the risk management of the activity (e.g. longer interview time with complex patients). Only the parameters estimated to have the greatest impact on the model output were assessed:
(i) the professional delivery time using interquartile ranges (IQR25, IQR75) [15];
(ii) the pharmacist and technician labour costs using +/− 20% of the base case values to account for the impact of professional experience level;
(iii) the number of EMs per patient using one and four EMs for the minimum and the maximum scenarios; and (iv) the doubling of trained professionals to ensure a full-time capacity to deliver the program.