Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence

BACKGROUND

Medication therapy management (MTM) programs are designed to improve clinical outcomes and enhance appropriate medication use. Comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) are 2 broad interventions defined within MTM services. While MTM services have been extensively researched, there are few comparisons of CMR versus non-CMR interventions. Given the variability in MTM interventions and lack of a consistent TMR definition in the literature, this study sought to compare CMRs and TMRs that were clearly defined based on Centers for Medicare & Medicaid Services (CMS) criteria.

OBJECTIVES

To (a) compare acute inpatient admissions and emergency department (ED) visits between patients participating in MTM services (CMR, TMR, or both) and eligible nonparticipating patients and (b) examine the effect of receiving TMR services on medication adherence.

METHODS

This was a retrospective cohort study of patients with Medicare Part D coverage who received MTM services and a 1:1 propensity score-matched control group. Participants had to be eligible for MTM services in 2014 or 2015 based on CMS requirements. CMRs were offered to all MTM-eligible patients, while TMRs were completed based on clinical rules that helped identify medication-related problems (MRPs). The date of MTM intervention, or eligibility for the control group, was considered the index date. Participants had to be continuously enrolled in a Medicare Advantage plan that included prescription drug coverage during the study period and have at least 6 months of data before and after the index date. Medical and pharmacy claims were assessed to examine trend-adjusted inpatient admissions and ED visits from pre-index to post-index date for participants and matched controls.

RESULTS

In 2014 and 2015, receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions. In 2014, there were 55.2 fewer admits per 1,000 individuals (95% CI = 29-81) and 30.8 fewer admits per 1,000 individuals in 2015 (95% CI = 20-42). Receipt of CMR-only interventions was associated with fewer acute inpatient admissions only when coupled with preidentification of MRPs (36.8 [95% CI = 25-49] fewer admits per 1,000 individuals). In 2015, there were significant reductions in ED visits for participants receiving TMR-only interventions or TMR/CMR interventions (26.1 [95% CI = 11-41] and 12.0 [95% CI = 1-23] fewer ED visits per 1,000 individuals, respectively). In both years, a larger percentage (0.4% for oral diabetes medications; 7.7% for antihypertensives; 3.0% for statins) of MTM participants had greater improvements in medication adherence in the post-index period compared with controls.

CONCLUSIONS

Receiving MTM services targeted at resolution of MRPs (TMR or CMR/TMR) resulted in positive reductions in health care utilization and increases in medication adherence. Given the importance of optimal medication utilization, this study highlights the need for additional focus on resolution of MRPs through TMRs and CMRs that can support improved clinical outcomes.

DISCLOSURES

No outside funding supported this study. Researchers completed the work as part of their employment with Humana. All authors are or were employees of Humana at the time of the study. There are no other conflicts of interest to disclose. This study was previously presented at AMCP Nexus 2017 on October 16, 2017, in Dallas, TX.

Retrospective analysis of outcomes following inferior vena cava (IVC) filter placement in a managed care population

The role of inferior vena cava filter (IVC) filters for prevention of pulmonary embolism (PE) is controversial. This study evaluated outcomes of IVC filter placement in a managed care population. This retrospective cohort study evaluated data for individuals with Humana healthcare coverage 2013-2014. The study population included 435 recipients of prophylactic IVC filters, 4376 recipients of therapeutic filters, and two control groups, each matched to filter recipients. Patients were followed for up to 2 years. Post-index anticoagulant use, mortality, filter removal, device-related complications, and all-cause utilization. Adjusted regression analyses showed a positive association between filter placement and anticoagulant use at 3 months: odds ratio (ORs) 3.403 (95% CI 1.912-6.059), prophylactic; OR, 1.356 (95% CI 1.164-1.58), therapeutic. Filters were removed in 15.67% of prophylactic and 5.69% of therapeutic filter cases. Complication rates were higher with prophylactic procedures than with therapeutic procedures and typically exceeded 2% in the prophylactic group. Each form of filter placement was associated with increases in all-cause hospitalization (regression coefficient 0.295 [95% CI 0.093-0.498], prophylactic; 0.673 [95% CI 0.547-0.798], therapeutic) and readmissions (OR 2.444 [95% CI 1.298-4.602], prophylactic; 2.074 [95% CI 1.644-2.616], therapeutic). IVC filter placement in this managed care population was associated with increased use of anticoagulants and greater healthcare utilization compared to controls, low rates of retrieval, and notable rates of device-related complications, with effects especially pronounced in assessments of prophylactic filters. These findings underscore the need for appropriate use of IVC filters.

204THE PRODUCTION OF INTRACYTOPLASMIC SPERM INJECTION LION (PANTHERA LEO) EMBYROS USING SPERMATOZOA COLLECTED BY PERCUTANEOUS EPIDIDYMAL SPERM ASPIRATION FROM VASECTOMIZED MALES

Contraception and/or sterilization methods have become an essential component of many captive animal management programs. Sterilization techniques are considered to be the last resort if a viable contraceptive cannot be attained and are generally not considered reversible. The African lion (Panthera leo) is one species in which sterilization techniques have been routinely applied. The objective of this study was to develop and evaluate a method for the collection of spermatozoa from male lions that have been previously rendered sterile by vasectomy. Percutaneous epididymal sperm aspiration (PESA) is a technique in which spermatozoa are aspirated from the epididymis and no surgical incision is required. In the present study, two lions (12 and 19 yrs old) were anesthetized and PESA was attempted. A 21-gauge needle attached to a 10-mL syringe (Norm-Ject) filled with 2–3mL of Tyrodes HEPES medium was gently inserted into the head of the epididymis and aspirated gently until spermatozoa were noted. Spermatozoa were visually assessed for motility (grade 1–5; 1=few motile sperm to 5=all motile), sperm concentrations were determined and then the sperm were cryopreserved. The total sperm concentration collected from the older (19yr) male was lower than that obtained from the younger (12yr) lion (0.08×106sperm/mL v. 65.5×106sperm/mL, respectively). Furthermore, more motile spermatozoa (grade 3) were collected from the younger individual compared to the older male (grade 1). Sperm samples from the 12-yr-old lion were frozen by multi-step addition of TEST yolk buffer+glycerol. Lionesses (n=3) were subjected to laparoscopic oocyte retrieval after gonadotropin treatment. A total of 38 oocytes were retrieved and 74% (28/38) were mature as determined by extrusion of the first polar body. Mature oocytes were subjected to ICSI using frozen-thawed spermatozoa obtained by PESA. More than 60% (17/28) of the injected oocytes cleaved and 100% (17/17) reached the morula stage by Day 5 or 6 of IVC. Embryos were cryopreserved and were subsequently transferred (n=15) into one lioness. We have demonstrated that it is possible to collect viable spermatozoa from sterile male lions using the PESA technique. Spermatozoa collected were motile and could be cryopreserved and functional for assisted reproductive techniques. This technique could be applied to other infertile or sterile males whose genetic background would benefit a current conservation program.

Pushing the quality envelope: a new outcomes management system

This article is based on the authors' experience in designing and implementing outcomes management systems for large managed care organizations. Topics addressed include design of instruments, use of cost-effective technology, development of computerized decision-support tools, and methods for case-mix adjustment. The case-mix-adjustment models are based on a data repository of several thousand treatment cases with multiple measurement points across the course of treatment. Data from controlled and field studies are described. These data suggest that the outcomes management methods outlined in this article can result in significantly improved clinical outcomes and a more rational allocation of behavioral health care resources.

Flexibility and Strength Measures in Children Participating in a Cardiac Rehabilitation Exercise Program

In brief: The purpose of this study was to evaluate the effects of a structured rehabilitation program on the strength and flexibility of children with surgically corrected congenital heart disease. Twelve children (eight boys, four girls) participated in one-hour exercise classes, two times per week for 12 weeks. Results showed minimal changes in upper extremity strength, but lower extremity strength improved 10% and 5% on the right and left sides, respectively. Flexibility improved about 25% in the lower extremities. Improvement was also noted in neck flexion, hip and oblique rotation, hamstring and low back stretch, and heel cord stretch. These findings indicate that this type of program can improve strength and flexibility in children who have undergone complex heart surgery and may help them achieve a more normal life-style.

Coexistent renal, müllerian and alimentary tract developmental defects. A case report

Unilateral renal agenesis has been found independently in relation to müllerian tract and alimentary tract abnormalities. We treated a woman for coexistent developmental defects in the renal, müllerian and alimentary tracts.