VOL. 15, NO. 5 n THE AMERICAN JOURNAL OF MANAGED CARE n฀ 281 n CLINICAL n © Managed Care & Healthcare Communications, LLC R ecent studies indicate that laboratory monitoring of medica- tions at initiation of therapy is below the level recommended by guidelines, with as many as 39% of patients not receiving recommended testing. 1 Lack of monitoring is a concern because of po- tential adverse events (eg, hyperkalemia associated with inhibitors of angiotensin) and because of failure to achieve therapeutic benefit due to inadequate blood levels of medication. Additionally, failure to es- tablish baseline levels makes it difficult to determine a patient’s trends in laboratory values. These concerns regarding patient safety and clinical effectiveness have led researchers to test methods to enhance laboratory-based medi- cation monitoring. Several types of interventions (including pharmacy- led efforts, electronic reminders to clinicians, and automated telephone call reminders to patients) to improve laboratory monitoring of medica- tions at therapy initiation have been effective in randomized trials. 1,2 Although all these interventions improve monitoring, the most ef- ficient intervention methods are not clear, and no economic analyses have been done to inform policy makers in this area. Some efforts may be particularly resource intensive, but could be worth the added expen- diture when the potential adverse outcome is severe. Without careful analysis of the balance between costs and benefits, one cannot determine which (if any) interventions ought to be funded by healthcare payers. The efficiency of alternative approaches to therapeutic monitoring is of growing importance to healthcare providers as this monitoring is now a focus of quality measurement. 3 To help with decision making regarding laboratory-monitoring interventions, we undertook a preplanned cost- effectiveness analysis of a randomized trial that tested several interven- tions aimed at enhancing laboratory monitoring of medication. 2 METHODS Trial Design Complete details of the trial design are available elsewhere. 2 The study was conducted at a not-for-profit, group-model HMO and was approved by its institutional review board. All HMO patients who had not received baseline laboratory tests (defined as within 6 months be- fore or 5 days after a newly dispensed study medication) were randomized to 1 of 4 conditions: an electronic In this issue Take-Away Points / p282 www.ajmc.com Full text and PDF Improving Laboratory Monitoring of Medications: An Economic Analysis Alongside a Clinical Trial David H. Smith, RPh, PhD; Adrianne C. Feldstein, MD; Nancy A. Perrin, PhD; Xiuhai Yang, MS; Mary M. Rix, RN; Marsha A. Raebel, PharmD; David J. Magid, MD; Steven R. Simon, MD; and Stephen B. Soumerai, ScD Objective: To test the efficiency and cost-effective- ness of interventions aimed at enhancing labora- tory monitoring of medication. Study Design: Cost-effectiveness analysis. Methods: Patients of a not-for-profit, group-model HMO were randomized to 1 of 4 interventions: an electronic medical record reminder to the clini- cian, an automated voice message to patients, pharmacy-led outreach, or usual care. Patients were followed for 25 days to determine comple- tion of all recommended baseline laboratory- monitoring tests. We measured the rate of labora- tory test completion and the cost-effectiveness of each intervention. Direct medical care costs to the HMO (repeated testing, extra visits, and interven- tion costs) were determined using trial data and a mix of other data sources. Results: The average cost of patient contact was $5.45 in the pharmacy-led intervention, $7 in the electronic reminder intervention, and $4.64 in the automated voice message reminder interven- tion. The electronic medical record intervention was more costly and less effective than other methods. The automated voice message interven- tion had an incremental cost-effectiveness ratio (ICER) of $47 per additional completed case, and the pharmacy intervention had an ICER of $64 per additional completed case. Conclusions: Using the data available to compare strategies to enhance baseline monitoring, direct clinician messaging was not an efficient use of resources. Depending on a decision maker’s willingness to pay, automated voice messaging and pharmacy-led efforts can be efficient choices to prompt therapeutic baseline monitoring, but direct clinician messaging is probably a less efficient use of resources. (Am J Manag Care. 2009;15(5):281-289) For author information and disclosures, see end of text.