Effect on health outcomes of a community-based medication therapy management program for seniors with limited incomes

Utilisation of the PRECEDE-PROCEED model in community pharmacy for health needs assessment: A narrative review

BACKGROUND

Health needs assessment tools such as the PRECEDE-PROCEED model (PPM) identify the key health concerns of communities, and may increase the capacity for community pharmacies to address these needs.

OBJECTIVES

A narrative review was conducted to investigate to what extent the PPM has been used to guide pharmacy service development and evaluation.

METHODS

A systematic search of six databases was conducted for peer-reviewed papers published from January 2000 to August 2019 that described the application of the PPM within the community pharmacy context. Search terms included variations of the following: 'pharmacists', 'precede proceed', 'pharmaceutical services', and 'community pharmacies'. Data extracted and analysed included study design, objectives, population, utilisation of the PPM, and outcomes.

RESULTS

Fourteen eligible papers were identified, most of which were cohort or cross-sectional studies and utilised at least one element of the PPM to design or evaluate interventions that targeted either patient behaviours or pharmacist behaviours, or evaluated population health needs or programs. The range of behaviours assessed was limited to patient medication adherence, and billing behaviours, readiness for expanded scope of practice, and communication for pharmacists. None of the studies prioritised community health needs, actively engaged all relevant stakeholders, or utilised every element of the PPM.

CONCLUSIONS

The PPM has been underutilised in community pharmacy research and represents an effective method for the assessment of health priorities for communities and the development and evaluation of health services targeted at addressing these priorities. Further research needs to demonstrate how key health needs assessment principles such as stakeholder engagement and a population-centred approach can influence effective health service delivery.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program

OBJECTIVES

To evaluate changes in acute health services use of Senior PharmAssist participants.

DESIGN

Retrospective analysis.

SETTING

Community-based, nonprofit program in Durham County, North Carolina.

PARTICIPANTS

Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017.

INTERVENTION

Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist.

MEASUREMENTS

Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years.

RESULTS

Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23).

CONCLUSION

Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Optimizing pharmacotherapy in elderly patients: the role of pharmacists

As the world's population ages, global health care systems will face the burden of chronic diseases and polypharmacy use among older adults. The traditional tasks of medication dispensing and provision of basic education by pharmacists have evolved to active engagement in direct patient care and collaborative team-based care. The care of older patients is an especially fitting mission for pharmacists, since the key to geriatric care often lies with management of chronic diseases and polypharmacy use, and preventing harmful consequences of both. Because most chronic conditions are treated with medications, pharmacists, with their extensive training in pharmacotherapy and pharmacokinetics, are in a unique and critical position in the management of them. Pharmacists have the expertise to detect, resolve, and prevent medication errors and drug-related problems, such as overtreatment, undertreatment, adverse drug events, and nonadherence. Pharmacists are also competent in critically reviewing and applying clinical guidelines to the care of individual patients, and in some instances confront the lack of data (common in older adults) to provide the best possible patient-centered care. The current review aimed to depict the evidence of geriatric pharmacy care, demonstrate current impact of pharmacists' interventions on older patients, survey the tools used by pharmacists to provide effective care, and explore their role in pharmacotherapy optimization in elders. The findings of the current review strongly support previous studies that showed positive impact of pharmacists' interventions on older patients' health-related outcomes. There is a clear role for pharmacists working directly or collaboratively to improve medication use and management in older populations. Therefore, in global health care systems, teams caring for elders should involve pharmacists to optimize pharmacotherapy.

EHR-based medication support and nurse-led medication therapy management: rationale and design for a three-arm clinic randomized trial

BACKGROUND

Patients with chronic conditions often use complex medical regimens. A nurse-led strategy to support medication therapy management incorporated into primary care teams may lead to improved use of medications for disease control. Electronic health record (EHR) tools may offer a lower-cost, less intensive approach to improving medication management.

METHODS AND RESULTS

The Northwestern and Access Community Health Network Medication Education Study is a health center-level cluster-randomized trial being conducted within a network of federally qualified community health centers. Health centers have been enrolled in groups of 3 and randomized to (1) usual care, (2) EHR-based medication management tools alone, or (3) EHR tools plus nurse-led medication therapy management. Patients with uncontrolled hypertension who are prescribed ≥ 3 medications of any kind are recruited from the centers. EHR tools include a printed medication list to prompt review at each visit and automated plain-language medication information within the after-visit summary to encourage proper medication use. In the nurse-led intervention, patients receive one-on-one counseling about their medication regimens to clarify medication discrepancies and identify drug-related concerns, safety issues, and nonadherence. Nurses also provide follow-up telephone calls following new prescriptions and periodically to perform medication review. The primary study outcome is systolic blood pressure after 1 year. Secondary outcomes include measures of understanding of dosing instructions, discrepancies between patient-reported medications and the medical record, adherence, and intervention costs.

CONCLUSIONS

The Northwestern and Access Community Health Network Medication Education Study will assess the effects of 2 approaches to support outpatient medication management among patients with uncontrolled hypertension in federally qualified health center settings.

Geriatric patient care by U.S. pharmacists in healthcare teams: systematic review and meta-analyses

OBJECTIVES

To conduct a systematic review and meta-analyses to examine the effects of pharmacists' care on geriatric patient-oriented health outcomes in the United States (U.S.).

DESIGN

Studies examining U.S. pharmacists' patient care services from inception of the databases through July 2012 were searched. The databases searched include PubMed/MEDLINE, Ovid/MEDLINE, ABI/INFORM, Health Business Fulltext Elite, Academic Search Complete, International Pharmaceutical Abstracts, PsycINFO, Cochrane Database, and Clinical Trials.gov. Studies reporting pharmacists' intervention for geriatric patients, comparison groups, and patient-oriented outcomes were assessed. Dual review for inclusion and data extraction were performed.

SETTING

University of Arizona College of Pharmacy.

MEASUREMENTS

Study and participant characteristics, pharmacist intervention, and outcomes with data for meta-analyses were collected. A forest plot was constructed to obtain a pooled standardized mean difference using a random effects model.

RESULTS

One hundred fifty-two articles were reviewed, with 20 resulting studies included in the final meta-analyses. Study sample size ranged from 36 to 4,218, with mean age of subjects being 65 and older. The studies were most frequently conducted in ambulatory care clinics, followed by inpatient settings; the majority focused on multiple diseases and conditions. Pharmacist activities varied widely, with technical interventions used most often. Favorable results were found in all outcome categories, and meta-analyses conducted for therapeutic, safety, hospitalization, and adherence were significant (P < .001), favoring pharmacist care over comparison. Some identifiable variability existed between included studies.

CONCLUSION

Pharmacist intervention has favorable effects on therapeutic, safety, hospitalization, and adherence outcomes in older adults. Pharmacists should be involved in team-based care of older adults.

Understanding the landscape of MTM programs for Medicare. Part D: Results from a study for the Centers for Medicare & Medicaid services

OBJECTIVES

To describe the features of medication therapy management (MTM) programs, including eligibility criteria, enrollment, services, and reimbursement, and to describe the criteria used to evaluate MTM programs and assess the evidence of relevance to Medicare.

DESIGN

Descriptive, exploratory, nonexperimental study.

SETTING

United States between July 2007 and June 2008.

PARTICIPANTS

60 key informants from 46 different organizations and case studies with 28 representatives from four MTM programs.

INTERVENTION

Literature review, key informant interviews, and evaluation of case studies.

MAIN OUTCOME MEASURES

MTM program features and evidence of effectiveness.

RESULTS

MTM programs used a variety of practice models. Medicare MTM programs used different eligibility criteria than MTM programs sponsored by Medicaid or other payers. MTM programs that required patients to opt-in had less success in enrolling participants than those using opt-out. Most MTM programs conducted annual medication reviews. Most non-Medicare MTM programs provided face-to-face interventions, whereas Medicare MTM programs relied more on telephone or mail; no research tested the effectiveness of different modes. Almost all MTM programs used pharmacists to provide services. Little research on Medicare MTM programs was available. Costs were commonly measured in the MTM literature, although results were inconsistent. A few studies demonstrated significant improvements in intermediate outcomes (e.g., low-density lipoprotein cholesterol), while less studies demonstrated an impact on serious sequelae (e.g., emergency department visits).

CONCLUSION

Medicare MTM programs were still evolving when this study was conducted, and we found limited evidence to determine which beneficiaries would benefit most from MTM, which features achieved the desired outcomes, and which outcomes should be measured to compare MTM program performance.

Conjoint analysis of patient preferences on Medicare medication therapy management

OBJECTIVES

To identify attributes of medication therapy management (MTM) valued by Medicare beneficiaries and to determine patient preferences and willingness to pay for MTM attributes.

DESIGN

Cross-sectional contingency valuation study.

SETTING

Six senior centers in Memphis, TN, from September 2007 through August 2008.

PARTICIPANTS

355 Medicare beneficiaries.

INTERVENTION

A discrete choice experiment was used, in which each study participant was asked to choose from two different hypothetical MTM services defined by seven attributes (service setting, provider type, number of drug therapy problems, provider experience in overall practice, provider experience in geriatrics, time spent, and cost of MTM service) and associated levels.

MAIN OUTCOME MEASURES

Patient preferences for different attributes of MTM services and patients' estimated marginal willingness to pay for each attribute level.

RESULTS

Study participants viewed cost (relative importance 32.2%) as the most important attribute of MTM, followed by service setting (24.2%), provider experience in overall practice (19.5%), and provider experience in geriatrics (16.6%). Community pharmacies (β = 0.146, P = 0.007) were the most preferred environment for MTM services, followed by clinics, whereas telephone consultation was the least preferred environment (β = -0.349, P < 0.001). Study participants were willing to spend as much as $31.76 (95% CI 19.84-45.27) to trade telephone MTM for clinic-based MTM. They also were willing to pay $13.31 more (3.60-23.65) for MTM service at a community pharmacy compared with clinic-based MTM.

CONCLUSION

Health plans should consider developing community pharmacy-based MTM options, at least for Medicare beneficiaries without mobility limitations.

Pharmacists' acceptable levels of compensation for MTM services: a conjoint analysis

BACKGROUND

The Medicare Modernization Act of 2003 requires prescription drug plans to provide medication therapy management (MTM) services to Medicare beneficiaries who are at high risk for inappropriate use of medications. However, inadequate compensation has been a barrier for MTM expansion among pharmacists.

OBJECTIVES

The objective of this study was to determine pharmacists' acceptable levels of compensation for MTM services.

METHODS

A preference-based fractional factorial design of conjoint analysis was used by surveying 1524 active pharmacists in Tennessee. Pharmacists were asked to select between packages (scenarios) of MTM services that represented combinations of MTM attributes (characteristics). The MTM attributes included type of patient (new or returning), patient's number of chronic conditions (1, 3, or 6), patient's number of medications (4, 8, or 16), patient's annual drug costs ($2000, $3000, or $4000), service duration (15 minutes, 30 minutes, or 45 minutes), and price of MTM services ($30, $60, or $120). A survival analysis model was used to predict pharmacists' willingness to select 1 versus another MTM service package. Pharmacists' acceptable level of compensation was estimated as the marginal rate of substitution between the parameter estimates of an attribute and the price attribute of MTM.

RESULTS

The parameter estimates were -0.0303 (P<.0001) for service duration and 0.0210 (P<.0001) for price of MTM services, respectively, so pharmacists were willing to accept $1.44/min (0.0303/0.0210), or $86.4/h, for MTM services. Pharmacists' characteristics were associated significantly with their acceptable levels of compensation: years of practice was associated with a higher need for compensation, pharmacy ownership (vs nonowner) associated with a lower need, and having provided MTM previously (vs having not provided MTM) was associated with a higher need.

CONCLUSIONS

Pharmacists' acceptable level of compensation is in the higher part of current ranges from $30 to $100/h. To increase participation in MTM services, pharmacist compensation needs to be increased. Future studies might continue to corroborate the generalizability of findings from this study.

Disparity implications of Medicare eligibility criteria for medication therapy management services

OBJECTIVE

To determine whether there would be racial and ethnic disparities in meeting eligibility criteria for medication therapy management (MTM) services implemented in 2006 for Medicare beneficiaries.

DATA SOURCES/STUDY SETTING

Secondary data analyses of the Medical Expenditure Panel Survey (2004-2005).

STUDY DESIGN

Logistic regression and recycled predictions were used to test the disparities in meeting eligibility criteria across racial and ethnic groups. The eligibility thresholds used by health plans in 2006 and new thresholds recommended for 2010 were examined. Racial and ethnic disparities were examined by comparing non-Hispanic blacks (blacks) with non-Hispanic whites (whites) and comparing Hispanics with whites, respectively. Disparities were also examined among individuals with severe health problems.

PRINCIPAL FINDINGS

According to 2006 thresholds, the adjusted odds ratios for meeting eligibility criteria for blacks and Hispanics to whites were 0.36-0.60 (p<.05) and 0.13-0.46 (p<.05), respectively. Blacks and Hispanics would be 21-34 and 32-38 percent, respectively, less likely to be eligible than whites according to recycled predictions. Similar patterns were found using the 2010 eligibility thresholds and among individuals with severe health problems.

CONCLUSIONS

There would be racial and ethnic disparities in meeting MTM eligibility criteria. Future research is warranted to confirm the findings using data after MTM implementation.

Pharmacists' advancing roles in drug and disease management: a review of states' legislation

OBJECTIVES

To determine which states in the United States have provisions in place for pharmacist participation in drug and disease management programs and/or collaborative practice agreements and to provide comparison and discussion regarding such provisions. A secondary endpoint was the requirements of certification, credentialing, and registration with the specific state's rules and regulations.

DATA SOURCES

Information was gathered from states' statutes, rules, and regulations. Acquisition of each state's laws was achieved through various forms of electronic media. Data were accessed from January to March 2008.

DATA SYNTHESIS

19 states (38%) had specific provisions for disease management, 33 (66%) had provisions for drug therapy management, and 37 (74%) had provisions for collaborative practice. A total of 11 states (22%) specified that pharmacists receive specialized training to participate in such endeavors. Board approval or notification for collaborative practice agreements was required in 16 states (32%).

CONCLUSION

With varying degrees of autonomy and restriction, pharmacists in certain states have the ability to develop disease management and/or collaborative practice programs. For pharmacists to take advantage of these new direct patient care opportunities, knowing the rules and requirements of their state's legislation is essential.

Medication therapy management services: definitions and outcomes

In the US, the Medicare Modernization Act of 2003 required that Medicare Part D insurers provide medication therapy management (MTM) services (MTMS) to selected beneficiaries, with the goals of providing education, improving adherence, or detecting adverse drug events and medication misuse. These broad goals and variety in MTM programmes available make assessment of these programmes difficult. The objectives of this article are to review the definitions of MTMS proposed by various stakeholders, and to summarize and evaluate the outcomes of MTMS consistent with those that may be offered in Medicare Part D or reimbursed by State Medicaid programmes. MTM programmes are approved by the Centers for Medicare and Medicaid Services (CMS). Pharmacy, medical and insurance organizations have provided guidelines and definitions for MTM programmes, distinguishing them from other types of community pharmacy activities. MTM has been distinguished from disease state management because of the focus on medications and multiple conditions. It differs from patient counselling because it is delivered independent of dispensing and involves collaboration with patients and providers. There is no consensus on the recommended mode of delivery (i.e. face-to-face or by telephone) for MTM. A MEDLINE search was conducted to identify articles published after 2000 using the search terms 'medication therapy management' and 'medication management'. Studies with outcomes evaluating community-based programmes consistent with MTMS, regardless of MTMS reimbursement source, were included in the review. Seven publications describing four MTMS were identified. For each of the identified articles, we describe the study design, service setting, inclusion criteria and outcomes. An additional three surveys describing multiple MTMS were identified and are summarized. Finally, ongoing efforts by CMS to evaluate the success of MTMS in the US are described. To date, there are limited outcomes available for MTMS. The wide variety of MTMS offered means that evaluations of individual programmes are necessary. Despite the potential benefits of MTMS, there are numerous challenges to providing MTMS, including reimbursement, justification of the service and stakeholder acceptance of the services. There remains a need for adequately funded, prospective, controlled studies of MTM programmes using strong designs to advance our knowledge of the effectiveness of various interventions and methods of delivery, and for naturalistic studies assessing the impact of CMS approved MTM programmes.

Survey of Medication Therapy Management Programs Under Medicare Part D

OBJECTIVE

To describe and summarize the enrollment criteria and benefit designs for medication therapy management (MTM) programs offered throughout the United States during the first year of the Medicare Part D benefit.

DESIGN

Cross-sectional survey.

SETTING

United States between November 1, 2005, and June 30, 2006.

PARTICIPANTS

MTM benefit plan managers of major health insurance companies nationwide selected nonrandomly by the investigators from lists provided by the Centers for Medicare & Medicaid Services.

INTERVENTION

Telephone interview and/or e-mail 12-item survey with mostly open-ended questions.

MAIN OUTCOME MEASURES

Characteristics required for a patient to be enrolled in MTM programs and types of services provided along with modes of delivery.

RESULTS

Interviews were completed or surveys returned from 21 distinct MTM programs representing 70 health insurance plans covering 12.1 million Medicare enrollees. Of the MTM programs offered, 90.5% restricted their enrollment based on number of diseases, with a median of 3 (range, 2-5) diseases required; 57.1% restricted enrollment based on the type of chronic condition; and 95.2% had requirements for the number of medications (median, 6; range, 2-24) necessary for enrollment in the program. The most frequently provided MTM services were patient education (75.0% of programs),patient adherence (70.0%), and medication review (60.0%). The median number of different service types provided by MTM programs was 3 (range, 2-7). MTM program services included the use of mailed interventions (76.1%) and inhouse call centers (90.4%). While only 4 of the 21 MTM programscontracted with pharmacies to provide some or all of their MTM services, these plans covered a large number of beneficiaries (7.5 million lives).

CONCLUSION

MTM programs offered by prescription drug plans and Medicare Advantage plans were highly variable during the first year of the Medicare Part D benefit. Definitive evidence supporting the effectiveness of many of the most common interventions is lacking.