Managing drug-related morbidity and mortality in the patient-centered medical home.

BACKGROUND: The appropriate use of medications can influence quality performance measures and costs. Drug-related morbidity and mortality represents a public health challenge due to the ineffective and unsafe consequences of medication use. This article addresses the impact of team-based care that incorporates comprehensive medication therapy management on per capita expenditures, quality performance measures, and resolution of drug therapy problems. METHODS: A team-based medication therapy management system developed over 13 years in an integrated health system in 4 Minnesota innovation clinic sites was assessed in terms of: (1) differences in total median health expenditures compared with noninnovation clinics, (2) improvements on 5 performance benchmarks for patients with diabetes in comparison with statewide results, and (3) resolution of drug therapy problems. RESULTS: Spending growth was 11% less in innovation clinics than that in 38 noninnovation clinics. Median per member per month health care costs measured at 5 intervals over a 15-month period were significantly lower in innovation than in noninnovation sites (P=0.05). Forty percent of patients with diabetes in the innovation clinics achieved all 5 performance benchmark treatment goals in 2009, with a range from 34% to 45%, compared with the statewide result of 17.5% of patients achieving all 5 benchmarks. In addition, over 4000 drug therapy problems were reported to be resolved. CONCLUSIONS: Team-based care helped to achieve quality performance and control spending growth through medication therapy management in a patient-centered medical home innovation.

Clinical Impact of a Comprehensive Medication Management Service in Primary Health Care.

OBJECTIVE: To evaluate the clinical impact of a comprehensive medication management (CMM) service in a Brazilian primary health-care setting. METHODS: A quasi-experimental study has been carried out between July 2014 and November 2016 with patients who received the service in the primary care setting of a Brazilian city (n = 1057). Factors associated with drug therapy problems (DTP) detection in the initial assessment were evaluated by performing univariate and multivariate analyzes. To evaluate the impact of the CMM service, a linear regression model was constructed from the difference between the initial and final values of the clinical and laboratory parameters adjusted by multiple variables. RESULTS: A total of 1642 DTPs was identified, the most prevalent one being "nonadherence" (31.9%) and the "need for additional drug therapy" (22.9%). The use of 5 or more medications and the presence of 3 or more diseases were positively associated with the identification of 3 or more DTPs during the initial assessment. Even after multiple adjustments, a statistically significant reduction has been observed in the values of glycated hemoglobin, systolic blood pressure, low-density cholesterol, and total cholesterol. CONCLUSION: The CMM service contributed to the resolution of DTP and showed positive clinical impact in primary health care in the studied setting.

Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System.

BACKGROUND: Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. OBJECTIVE: To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. METHODS: Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. RESULTS: A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and well-being had improved because of MTM. CONCLUSION: Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high. DISCLOSURES: There was no external funding for this manuscript. The 3 authors are employees of Fairview Pharmacy Services. Ramalho de Oliveira had primary responsibility for the concept and design, writing, and revision of the manuscript, with the assistance of Brummel and Miller. Ramalho de Oliveira performed the data collection, and all 3 authors shared equally in data interpretation.

Implementation of medication management services at the primary healthcare level - a pilot study.

This study employed a mixed-method approach to enable the implementation of comprehensive medication management (CMM) services in Croatia's primary care setting. Drug therapy problems (DTPs) and factors associated with their occurrence were determined in patients with chronic diseases from January 2018 to April 2019. The pre-implementation stage established the foundations for the early implementation stage, in which the practice was set up, the patients' recruitment initiated and various challenges identified. During the study period, 86 patients were recruited for CMM provision. Overall, 2.8 DTPs (± 1.6) per patient were identified and the majority (96.2 %) presented with at least one DTP. Multiple regression analysis showed that type 2 diabetic patients (p = 0.025) and patients using five or more medications (p = 0.011) should be prioritized to receive CMM services as potentially they have a higher number of DTPs, and could, therefore, obtain a greater benefit from the service.

Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study.

PURPOSE: Patients with multiple chronic conditions (multimorbidity) often require ongoing treatment and complex self-care. This workload and its impact on patient functioning and well-being are, together, known as treatment burden. This study reports on factors that patients with multimorbidity draw on to lessen perceptions of treatment burden. PATIENTS AND METHODS: Interviews (n=50) and focus groups (n=4 groups, five to eight participants per group) were conducted with patients receiving care in a large academic medical center or an urban safety-net hospital. Interview data were analyzed using qualitative framework analysis methods, and themes and subthemes were used to identify factors that mitigate burden. Focus groups were held to confirm these findings and clarify any new issues. This study was part of a larger program to develop a patient-reported measure of treatment burden. RESULTS: Five major themes emerged from the interview data. These included: 1) problem-focused strategies, like routinizing self-care, enlisting support of others, planning for the future, and using technology; 2) emotion-focused coping strategies, like maintaining a positive attitude, focusing on other life priorities, and spirituality/faith; 3) questioning the notion of treatment burden as a function of adapting to self-care and comparing oneself to others; 4) social support (informational, tangible, and emotional assistance); and 5) positive aspects of health care, like coordination of care and beneficial relationships with providers. Additional subthemes arising from focus groups included preserving autonomy/independence and being proactive with providers. CONCLUSION: Patients attempt to lessen the experience of treatment burden using a variety of personal, social, and health care resources. Assessing these factors in tandem with patient perceptions of treatment burden can provide a more complete picture of how patients fit complex self-care into their daily lives.

Optimal diabetes care outcomes following face-to-face medication therapy management services.

Pharmacists play an integral role in influencing resolution of drug-related problems. This study examines the relationship between a pharmacist-led and delivered medication therapy management (MTM) program and achievement of Optimal Diabetes Care benchmarks. Data within Fairview Pharmacy Services were used to identify a group of patients with diabetes who received MTM services during a 2007 demonstration project (n=121) and a control group who were invited to receive MTM services but opted out (n=103). Rates of achieving optimal diabetes clinical management for both groups were compared using the D5 diabetes measure for years 2006, 2007, and 2008. The D5 components are: glycosolated hemoglobin (HbA1c<7%); low-density lipoprotein (<100 mg/dl); blood pressure (<130/80 mmHg); tobacco free; and daily aspirin use. Multivariate difference-in-differences (DID) estimation was used to determine the impact of 1 year of MTM services on each care component. Patients who opted in for MTM had higher Charlson scores, more complex medication regimens, and a higher percentage of diabetes with complications (P<0.05). In 2007, the percentage of diabetes patients optimally managed was significantly higher for MTM patients compared to 2006 values (21.49% vs. 45.45%, P<0.01). Nonlinear DID models showed that MTM patients were more likely to meet the HbA1c criterion in 2007 (odds ratio: 2.48, 95% confidence interval [CI]: 1.04-5.85, P=0.038). Linear DID models for HbA1c showed a mean reduction of 0.54% (95% CI: 0.091%-0.98%, P=0.018) for MTM patients. An MTM program contributed to improved optimal diabetes management in a population of patients with complex diabetes clinical profiles.

[The use of apetite inhibitors by women: an insight based on the gender perspective]. / O uso de inibidores de apetite por mulheres: um olhar a partir da perspectiva de gênero.

The scope of this study was to understand the motives that lead adult women to use appetite inhibitors and to establish, from a gender perspective, how these women relate to their own bodies. It was structured around the principles of qualitative research, and the methods of data collection were semi-structured interviews and direct observation. The informants were six women who used appetite inhibitors. The results indicated that images, publicity and social networks contribute significantly to the creation of new standards of physical appearance as well as lifestyles, which establish appearance (a slim body) and a happy marriage as the desired model. The slim body is represented as something able to alter the temperament of the individual, in other words a fat person is an unhappy person and a slim person is a happy person. The study shows that it is in the body per se that the social role destined for women is produced and reproduced.

Achieving patient centeredness in pharmacy practice: openness and the pharmacist's natural attitude.

OBJECTIVE: To present the benefits of openness for achieving patient centeredness by pharmacists, provide patient narratives from two qualitative research studies that demonstrated how patients have experienced pharmacists' traditional approach, and describe a tool with six component strategies for pharmacists to use in direct patient care. DESIGN: (1) Ethnographic study and (2) hermeneutic phenomenological study. SETTING: (1) Pharmaceutical care practices and (2) university. PARTICIPANTS: (1) Patients, practitioners, and student pharmacists, and (2) university faculty and staff taking long-term medications for chronic diseases. INTERVENTIONS: (1) Participant observation, in-depth interviews, focus groups, and analysis of documents, and (2) unstructured, in-depth interviews. MAIN OUTCOME MEASURES: (1) Observations and participant comments and (2) patient comments. RESULTS: Pharmacists' primary reliance on pharmacology and pharmacotherapy--without consideration of the patient as an individual--can devalue patients' personal understanding of their own situation and negatively affect care. This "natural attitude" of pharmacists, created through their preparation and education, involves their understanding of medications, focus on the product, use of counseling as the major approach with patients, and emphasis on medication adherence as a goal. Pharmacists as professionals must recognize how their natural attitude negatively affects care and work to become more patient-centered practitioners by the development of skills such as openness. Pharmacists can achieve openness by applying six strategies with patients (listen, acknowledge, wonder) and themselves and professional colleagues (recognize, question, reflect). CONCLUSION: Patients want to be heard and seen as individuals with unique experiences and responses to medications. If pharmacists are intent on working with patients to ensure that their medication-related needs are met, they should grasp what it means to be patient-centered, and the six strategies for achieving openness should be applied in the daily practice of pharmacy.