Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes | Page 2
Published Online: February 25, 2014
Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD; Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD
Unadjusted observed outcomes rates are presented in Table 2 for the entire cohort and in Table 3 for members that were enrolled in 2010. No differences were found in the unadjusted all-cause mortality rate between the 2 groups (5.7% in study group vs 5.6% in matched group), while the same mortality rate was significantly lower in the MTM group for the cohort enrolled in 2010 only (4.3% vs 5.0%, P <.001). In the pre-intervention period, the MTM group had a higher percentage of hospitalization compared with the control group (absolute between-group difference of +5.75%) and a higher percentage of ED visits (absolute difference of +9.3%) (Table 1). In the postintervention period, the MTM groups showed an absolute reduction in hospitalization of 4.1% while the control group showed an increase of 2.1% (absolute between-group differences of + 0.5%). Similar change was seen with ED visits with an absolute between-group difference of 6.2%, down from 9.3%. In the 2010 cohort, a significantly lower proportion of the MTM group was hospitalized (Table 3: 24.1% vs 24.9%), despite higher percentage of hospitalization in pre-period (27.3% vs 22.1%). We also observed a narrowing in the absolute difference in the percentage of ED visits (3.4% during study vs 7.7% before study). A difference in change of daily median prescription cost was also observed between the 2 study groups, with a median decrease of $0.39 for the MTM group and a median increase of $0.10 for the matched group (P <.001).
The adjusted outcomes comparing the MTM group with the matched group are presented in Table 4. The adjusted proportional hazard ratio for mortality was significantly lower at 0.86 (confidence interval [CI], 0.84-0.88, P <.001) for the entire cohort and at 0.71 (CI, 0.68-0.75, P <.001) for the 2010 cohort. The adjusted logistic regression analysis shows a significantly lower odds of hospital admission in the MTM group (odds ratio [OR] = 0.97 [CI = 0.94-0.99, P = .016] for the entire cohort and OR = 0.91 [CI 0.87-0.95, P <.001] for the 2010 cohort). The OR of ED visits was significantly higher in the MTM group. The change in daily medication costs for the MTM group was not different from the matched group.
In this large, retrospective, matched cohort study, we observed a 14% reduction in the risk of mortality, a 3% reduction in the risk of hospitalizations, 17% increased risk for ED visits, and no differences in change in median daily medication costs for MPD beneficiaries within 12 months after receiving MTM services, compared with a matched group of Medicare patients who did not receive MTM services. The same trend, but with a more profound magnitude, was observed in the subgroup enrolled in 2010 when the criteria for MTM services had changed. The improvement in patient outcomes may be due to a combination of services and interventions provided by MTM ambulatory care pharmacists. These interventions included optimizing medication regimens under physician-approved protocol, providing education on medication use to enhance patient understanding and appropriate use which may lead to increased adherence, ordering necessary laboratory testing, and coordination of care. Optimizing drug therapy by the pharmacist usually consisted of simplifying treatment regimens, titrating existing medication regimens to achieve therapeutic goals or reduce the likelihood of adverse reactions, initiating new medications when gaps in therapy were identified, discontinuing duplicate or unnecessary therapies, including drugs on the Beer’s List recommended to be avoided in the elderly; and switching drug therapy to avoid drug-drug interactions. These interventions may help achieve targeted clinical goals that benefit the patient’s health status.3,4,6,7 Lastly, participating MPD beneficiaries and plans providing MTM services can benefit economically by managing prescription drug costs through appropriate drug use, use of generics, and elimination of unnecessary medications. 6,8 These measures may reduce total drug spending and delay the time for MPD beneficiaries to reach the coverage gap (donut hole) and incur out-of-pocket costs. Although we did not observe a significant decrease in change of daily medication costs in this study, we were able to find improvement in other outcomes without an increase in medication costs. We do not have data on the number or type of interventions outlined above during 2006 to 2009 as they were not recorded in an analyzable format. In 2010, there were a total of 51,732 interventions recorded by the MTM program. The impacts of specific types of interventions warrant future study.
The results of this study support findings reported in the available literature. In a study by Welsh et al,10 a reduction in mortality risk was observed in patients enrolled in an MTM program (OR 0.5; 95% CI, 0.3-0.9). The results of our study did not show as great a decrease in mortality for the entire study population or the 2010 subgroup. This may be due to differences in study design between the 2 studies. Our study design included matching, with the intention of obtaining groups with similar cost burden using DxCG scores. Conversely, the study by Welsh et al compared patients who agreed to enroll in the MTM program with those who declined participation.
A mixed impact of the MTM programs on hospital admissions and ED visits was observed in the literature. Some studies have shown no difference or a reduction in hospital admissions, while others have shown an increase associated with MTM programs.8,10,14,22 Explanations for the reduction in proportion of patients being hospitalized include improved medication management, while the increase in hospitalizations may be due, in part, to a reduction in mortality. Our study demonstrated that there was a reduction in hospital admission but an increased rate of ED visits in a sicker MTM study population compared with a control group.
Similarly, studies have shown the impact of MTM on medication costs can vary due to a multitude of reasons.6-8,10 Reductions in medication costs include discontinuation of duplicate medications and those to be avoided in the elderly, and medications with an inappropriate indication. Increased medication costs may be due to the addition of medications identified as gaps in therapy, titrating of medications, and increased adherence.
This study, as far as we know, is the largest in size with 172,660 participants and a long follow-up time of 12 months to evaluate MTM services. The validity of our results was strengthened, as the size of the study population allowed us to detect very small differences in outcomes. Our study matched MTM to control patients by age, gender, location, and DxCG score. The ability to match at a 1:4 ratio also increased the power and provided greater precision in estimates and tests. We decided to use DxCG as a matching criterion because all but 1 of our outcomes was related to resource utilization. Matching non-MTM-eligible patients may avoid some of the selection bias. Several previous MTM studies analyzed populations of patients who opted in versus those who opted out of MTM participation. Patients who opted in for MTM services may have been more engaged in their healthcare, favoring results for patients enrolled in MTM. The matching in our study was not perfect, as subjects in MTM services had a higher disease burden at baseline, with greater hospitalization, ED visits, and medication costs. This may be due to the fact that eligibility for MTM required meeting a threshold annual medication cost and having multiple chronic conditions. The control group in our study were Medicare members, without 2 of the chronic conditions as stated in KP MTM criteria; or having a lowerthan- threshold annual Part D medication cost. After matching for age, gender, and DxCG, we found that our control group did not have the same disease burden in terms of prior hospitalization and ED visit rate and medications used, when compared with MTM study group. We used CCI and specific prior utilization to adjust the outcomes and conducted a difference in differences comparison in order to account for these baseline differences. It is impossible to conduct a cohort study that avoids all selection bias because MTM eligible patients have a higher disease burden by definition when compared to all non-eligible Medicare enrollees. The current study matched with a control group with less disease burden, based on baseline utilization. Hence, the primary outcome of mortality would be expected to be lower in the control group. Yet, we observed a favorable mortality rate in our MTM intervention group.
Given that KP is an integrated care system and the current study was limited to patients in California, there might be limited generalizability of the results.
The retrospective nature of this study inherently requires a level of caution when interpreting the results. Our study did not examine into what specific components or processes from the MTM program were associated with the outcomes. For example, pharmacist-led discontinuation of skeletal muscle relaxants, a class of medications to be avoided in the elderly, may have been a significant factor in the reduction in inpatient hospitalization. We also did not evaluate any surrogate markers, such as blood pressure, lipid levels, or glycated hemoglobin. Since the 2 groups were not matched on disease burden and not everyone would have these surrogate markers measured during the time period, we decided to look at outcomes that we could observe for the entire cohort. We also did not estimate the return on investment for the MTM services provided at KP California, as other studies had investigated this matter extensively.6-8,23,24
This study is the largest to date, helping to supplement and strengthen available literature. Studies such as ours are essential to ensure that MTM services continue to provide a positive impact on health outcomes. The KP California Medicare MTM program provides targeted services that, when combined with other healthcare services, are likely to improve patient outcomes. Although the direct effect of specific interventions was not investigated, it can be noted that there is a reduction in mortality and inpatient hospitalizations when usual care is supplemented with a pharmacist-led MTM program.
Author Affiliations: Pharmacy Outcomes Research Group, Kaiser Permanente Drug Information Services (RLH, MMS, JC); Kaiser Permanente Drug Information Services, PGY-2 Pharmacy Resident in Drug Information (BDY); Kaiser Permanente Southern California Medicare Medication Therapy Management (EWJ).
Funding Source: This study was funded by Kaiser Permanente Drug Information Services.
Authorship Information: Concept and design (RLH, BDY, MMS, JC); acquisition of data (RLH, MMS); analysis and interpretation of data (RLH, BDY, MMS, EWJ, JC); drafting of the manuscript (RLH, BDY, EWJ); critical revision of the manuscript for important intellectual content (RLH, BDY, MMS, EWJ, JC); statistical analysis (RLH, BDY); provision of study materials or patients (EWJ); administrative, technical, or logistic support (RLH).
Author Disclosures: The authors (RLH, BDY, MMS, EWJ, JC) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Address correspondence to: Rita L. Hui, PharmD, MS, 1800 Harrison St, Ste 1301, Oakland, CA 94612. E-mail: Rita.L.Hui@kp.org
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