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Improving Medication Adherence in Primary Care

Dec 15, 2020
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Melinda Rodriguez, PharmD Candidate 2021, Lake Erie College of Osteopathic Medicine – L|E|C|O|M School of Pharmacy

Pharmacist-led medication therapy management (MTM) has been shown to improve medication adherence. 

The accountable care organization (ACO) health care delivery model comprises a network of providers who share responsibility for coordinating quality, value-based care. This model is becoming more common in today’s practice. The Medicare Shared Savings Program (MSSP), for example, uses the ACO model to assure quality care for its beneficiaries. Quality is measured through Medicare Star Rating System. Ratings can range from 1 to 5 stars – programs that receive higher star ratings are eligible to receive Quality Bonus Payments. It has been known that pharmacist-provided care has the potential to affect ACO quality benchmark measures positively. However, there are still several challenges that prevent the full integration of pharmacists into primary care-based ACOs. A group of dedicated pharmacy practice faculty from Nova Southeastern University College of Pharmacy in Florida founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED) to overcome these challenges and detail areas where pharmacists can be integrated to improve ACO measures. The 2015 report from the ACORN SEED focused on five opportunities to improve medication use in ACOs in the primary care setting: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. Its newest report published in June 2020 focuses on the effects of a pharmacist-led medication therapy management (MTM) clinic on medication adherence, particularly for chronic medications such as renin-angiotensin system antagonists, antidiabetic agents, and statins.  

 

MTM services aim to target therapeutic duplicates, adverse effects, medication adherence, and medication misuse. In this role, pharmacists can review patients’ medical histories and medication records to create an action plan, coordinate an intervention in collaboration with the prescriber, or refer patients. Research has shown that pharmacist-led MTM can reduce costs, improve patient care, and decrease physician workloads. Additionally, studies have reported enhanced medication adherence with pharmacist-led MTM services. A retrospective cohort study conducted by ACORN SEED used the Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Rating System to measure differences in adherence between pre-and post-pharmacist MTM intervention. Chart reviews were conducted to collect pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Humana HMO Medicare beneficiaries with at least one chronic condition requiring treatment with a renin-angiotensin system antagonist, antidiabetic agent, or statin were eligible for the study. The outcome of interest was the change in medication adherence Star Ratings following MTM intervention by a pharmacist. Out of a total of 102 patients referred to the MTM clinic, 32 had follow-up visits, and 25 interventions had been made. Star ratings averaged roughly 3 out of 5 stars in the year before pharmacist interventions. After the interventions, ratings increased to 4 and 5 stars across different drug categories showing marked improvements in patient adherence, awareness, engagement, and care satisfaction.  

Similar results have been seen in numerous studies. The University of California, San Francisco, School of Pharmacy developed and implemented a pharmacist-led, patient-centered MTM program. This program used motivational interviewing, coaching, skills assessments, and train-the-trainer strategies to improve patient adherence to three major medication classes: antihypertensives, antihyperlipidemic, and antidiabetic medications. The results showed a 9% increase in adherence rate and a 1-2 star increase in Star Ratings over five years. An article describing the best practices of Fairview Pharmacy Services’ MTM program acknowledges the accomplishments of 23 MTM pharmacists who, with their skillsets, have conducted pharmacotherapy workups, identified drug-related problems, ensured safe and effective drug therapies, and increased compliance for the 20,000-plus patients served over the last 22 years. A review of their data showed that over 107,000 medication-related problems had been identified and resolved in 30 different locations. Data since 2007 revealed that the percentage of patients with diabetes optimally managed (as measured by HbA1c, LDL, blood pressure, aspirin use, smoking status) was significantly higher for MTM patients (45% versus 21%, P < 0.01). Fairview MTM also showed a 12:1 return on investment comparing overall healthcare costs of patients receiving MTM services versus patients who did not receive the benefits. 

Reports have shown several areas where pharmacists have improved medication use in primary care settings. Disease state management and MTM are among those areas where pharmacists can play an essential role within ACOs. By targeting high-risk patients and medication-related problems, pharmacists can reduce healthcare costs and physician workloads while decreasing unnecessary physician visits, hospital readmissions, and emergency department visits. Patients have reported improved medication adherence when pharmacists manage their medications, identifying duplicate therapies, reducing adverse drug events, and optimizing outcomes. With accountable care becoming the cornerstone of health care delivery, programs involving pharmacists will become increasingly common. Increasing awareness of pharmacists’ roles in primary care may be the first step in overcoming barriers to integrating pharmacists in Accountable Care Organizations. 

 Practice Pearls: 

  • Pharmacists can improve patient adherence in primary care-based ACOs. 
  • Patients may be more engaged in their health care when pharmacists intervene.  
  • HEDIS Star Ratings increased by 1-2 stars when pharmacists led MTM clinics. 

 

Hale G, Moreau C, Joseph T, et al. Improving Medication Adherence in an ACO Primary Care Office with a Pharmacist-Led Clinic:  

Spears J, Erkens J, A Pharmacist-Led, Patient-Centered Program Incorporating Motivational Interviewing for Behavior Change to Improve Adherence Rates  

Brummel A, Lustig A, Westrich K, et al. Best practices: improving patient outcomes and costs in an ACO through comprehensive medication therapy management.  

Joseph T, Hale GM, Eltaki SM, et al. Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations 

 

Melinda Rodriguez, PharmD Candidate 2021, Lake Erie College of Osteopathic Medicine – L|E|C|O|M School of Pharmacy