Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes | Page 4
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
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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