Early impact of the 2018 AHA/ACC/multisociety cholesterol guideline on lipid monitoring after statin initiation.

BACKGROUND: The 2018 AHA/ACC/multisociety cholesterol guideline emphasizes the need for lipid monitoring more strongly than the previous 2013 guideline to ensure patients reach recommended percent low-density lipoprotein cholesterol reductions. Real-world compliance to monitoring recommendations is currently unknown. OBJECTIVES: This study examined the proportion of patients with a lipid panel measured within 3 months of statin initiation. METHODS: This retrospective cohort study evaluated University of Colorado Health primary care patients aged 18 to 89 years with a new statin prescription identified via the Epic Clarity database. Patients initiated on a statin during January 1, 2018 to June 30, 2018 and January 1, 2019 to June 30, 2019 were included in the pre-2018 guideline cohort and the post-2018 guideline cohort, respectively. Patients with active liver disease, pregnancy, or missing demographic data were excluded. RESULTS: A total of 13,726 patients were included, 7476 in the preguideline cohort and 6250 in the postguideline cohort. A total of 13.9% of patients in the preguideline cohort had a lipid panel completed within 3 months of statin initiation compared with 16.2% in the postguideline cohort (adjusted P < .001). In the postguideline cohort, 56% (n = 857) of patients with lipid monitoring warranted a therapeutic intensification as recommended by the 2018 guideline; however, only 5% had their lipid-lowering regimen changed. CONCLUSION: In a large integrated health system, lipid monitoring increased among patients newly started on statin therapy soon after release of the 2018 guideline but remains low. Clinical interventions are needed to improve lipid monitoring to optimize low-density lipoprotein cholesterol-lowering therapy and ensure that guideline-recommended goals are achieved.

Blood pressure control rates measured in specialty vs primary care practices within a large integrated health system.

Blood pressure measurement is a diagnostic test and a key component of assessing and managing hypertension, a major contributor to cardiovascular risk. Based on real-world clinical observations within a large, university-based, accountable care organization, we sought to assess whether blood pressure control results varied by the assessment setting, primary care versus specialty. We studied the most recent outpatient measurement for patients with hypertension during the 2016 calendar year and categorized each as being performed in a primary care or specialty setting, and as being controlled (<140/90 mm Hg) or uncontrolled. Among the 86 512 patients identified, the 43 364 whose most recent blood pressure measurement was in a specialty setting were significantly less likely to be controlled compared to the 43 148 whose most recent measurement was in primary care (63% vs 68%, respectively, OR = 0.83 [0.80-0.85]). For the 27 955 patients who had measurements performed in both settings during the year, the control rates based upon their most recent specialty and primary care measurements were 63% and 71%, respectively (OR = 0.62, 0.60-0.65). For the subsets of patients whose measurements in each setting were within 30 or within seven days of each other, the odds of control in the specialty versus primary care setting were 0.63 (0.58-0.75) and 0.65 (0.57-0.75), respectively. Health systems should weigh the value of performing blood pressure measurement in specialty settings that do not manage this condition, taking into consideration the resources required to perform it and the potential negative consequences of inaccurate measurements.

Labor costs and economic impact of a primary care clinical pharmacy service on postfracture care in postmenopausal women.

STUDY OBJECTIVE: To compare costs associated with two osteoporosis management interventions and to quantify cost avoidance due to projected hip fracture prevention. DESIGN: Labor and cost analysis within a retrospective cohort study. SETTING: Integrated health care delivery system. PATIENTS OR PARTICIPANTS: Women aged 67 or older with a documented fracture between January 1 and December 31, 2007, managed by either a Clinical Pharmacy Osteoporosis Management Service (CPOMS) or comparator service using a registered nurse (RN). Recommendations included dual-energy x-ray absorptiometry (DEXA) scans and/or bisphosphonate therapy as appropriate. MEASUREMENT AND MAIN RESULTS: The primary end points were cost per patient reviewed, cost per patient achieving the quality end point of completing a DEXA scan or purchasing an antiosteoporosis medication, and cost avoidance due to projected hip fracture prevention. A total of 1129 women were managed by either CPOMS (n=827) or the comparator service (n=302). The cost of provider time for CPOMS and comparator group interventions was $25 ($21-$30) and $34 ($21-$53) per patient reviewed, respectively. The cost per patient achieving the quality end point was $92 ($77-$112) and $198 ($124-$307), respectively. If women in the CPOMS group persisted in receiving their bisphosphonate for 1 year, approximately two additional hip fractures would be avoided per 1000 patients reviewed. Based on this model, the projected annual cost of osteoporosis care for 1000 women was $619,736 (CPOMS) versus $726,887 (comparator service). CONCLUSIONS: The CPOMS resulted in comparable cost per patient reviewed but a lower cost per patient achieving quality end points. When including costs associated with projected hip fractures, CPOMS was less expensive than the comparator group because more patients initiated drug therapy, which resulted in fewer projected hip fractures. From the health care payer's perspective, the CPOMS intervention is associated with a lower cost per patient achieving treatment recommendations while providing future cost savings because of fewer hip fractures.

Cost-effectiveness evaluation of a home blood pressure monitoring program.

OBJECTIVES: To evaluate the health system cost of a home blood pressure monitoring (HBPM) program versus usual care in an integrated healthcare system. STUDY DESIGN: This cost-effectiveness analysis was based upon a previously completed randomized controlled trial of 348 hypertensive patients, in which mean systolic blood pressure (BP) was lowered 21 versus 8 mm Hg in the HBPM and usual care groups, respectively, and BP control was achieved in 54% versus 35% of patients (P < .001). METHODS: This analysis compared direct costs from the health plan perspective, including clinic visits, e-mail and telephone encounters, laboratory tests, medications, hospitalizations, and emergency department visits between the 2 groups. Primary outcomes were the incremental hypertension care-related cost of HBPM per mm Hg lowering of systolic BP per patient, per additional BP controlled, and per life-year gained. RESULTS: Median hypertension-related cost per patient over 6 months was $455 in the HBPM group and $179 for usual care (P < .001). This increase was attributable to additional e-mail and telephone encounters, greater antihypertensive medication use, additional laboratory monitoring, and the BP monitor. Median total cost per patient was $1530 and $1283 for the HBPM and usual care groups, respectively (P = .034). The HBPM program increased hypertension-related expenditures by $20.50 per mm Hg lowering of systolic BP, $1331 per additional patient achieving BP control at 6 months, and $3330 per life-year gained. CONCLUSIONS: The HBPM program requires investment in outpatient encounters, medications, and laboratory monitoring, but produces significantly improved BP control.

Evolution, current structure, and role of a primary care clinical pharmacy service in an integrated managed care organization.

The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.

Impact of a pharmacist-directed intervention in postmenopausal women after fracture.

PURPOSE: The impact of decentralized clinical pharmacy services on the implementation of appropriate care in postmenopausal women with a recent history of a fracture was assessed. METHODS: Women 67 years of age or older with a documented fracture between January 1 and December 31, 2007, were identified in two geographic regions. At the intervention site, a decentralized clinical-pharmacy-based osteoporosis management service (CPOMS) intervened on postmenopausal women following fracture, while the comparison group utilized a centralized registered nurse to manage this population. In both groups, interventions included initiation of either osteoporosis medication or bone mineral density (BMD) screening. RESULTS: Of the 827 women in the CPOMS group, 65% (523) initiated a medication for osteoporosis or completed BMD screening within 6 months of the fracture, compared with 46% (139) of the 302 women in the comparison group (p < 0.001; cumulative incidence ratio [CIR], 1.75; 95% confidence interval [CI], 1.44-2.12). CPOMS patients were nearly twice as likely as comparison group patients to purchase osteoporotic medications (42% [347 of 827] versus 24% [73 of 302]; CIR, 1.89; 95% CI, 1.50-2.40) and equally likely to undergo BMD testing (35% [289 of 827] versus 31% [94 of 302]; CIR, 1.13; 95% CI, 0.91-1.39). Both interventions achieved results substantially higher than national averages. Of patients receiving a medication and continuous membership for 12 months, adherence was also significantly higher in the CPOMS group (46% [39 of 291] versus 28% [20 of 71], respectively; p = 0.007). CONCLUSION: An integrated pharmacist-run osteoporosis management service demonstrated a substantial increase in the rate of osteoporosis drug initiation among post-menopausal women who experienced a fracture compared with a centrally located nurse-run service. BMD screening rates did not significantly differ between groups.

Actual versus projected cost avoidance for clinical pharmacy specialist-initiated medication conversions in a primary care setting in an integrated health system.

BACKGROUND: Primary care clinical pharmacy specialists (PCCPSs) are positioned to promote effective, safe, and affordable medication use. Documentation of performed interventions is difficult because the diversity of performed interventions in a variety of disease states in some practice settings. Validation of cost-avoidance projections is also difficult because traditional projection methods have several limitations. OBJECTIVE: To (1) compare projected medication cost avoidance (MCA) to actual MCA for medication conversions related to hyperlipidemia, hypertension, depression, and chronic pain initiated by PCCPS, and (2) estimate medication discontinuation that might be attributable to serious adverse drug events (ADEs) possibly associated with medication conversions. METHODS: This was a retrospective, longitudinal study conducted in a not-for-profit, integrated health system comprising approximately 470,000 members. Using a portable documentation tool, PCCPSs recorded projected annual MCA for medication conversions in 4 disease conditions (i.e., hypertension, dyslipidemia, depression, and chronic pain) in the 6-month period from December 1, 2003, through May 31, 2004. Actual annual MCA for these interventions for a 1-year follow-up period was calculated using integrated, electronic data from an administrative pharmacy database. Comparisons were made between projected MCA and actual MCA. Cost was defined as actual drug acquisition cost. In addition, an assessment of serious ADEs potentially related to the conversions was undertaken by reviewing electronic medical records of converted, nonpersistent patients. RESULTS: There were 704 medication conversions for 656 patients, of which 47 (6.7%) were for members who disenrolled in the health plan during the 12 months following the medication conversion date. The total projected MCA was $327,337 in 2004 dollars, or an average of $465 per conversion. For the 657 medication conversions in 609 patients that were evaluable (i.e., the member remained enrolled through 12 months follow-up), 466 (70.9%) persisted at 12 months, 138 (21.0%) discontinued the medication or converted to an alternative therapy, and 53 (8.1%) reverted to the original medication. Drug cost information was not available for some members, leaving approximately half (n = 331, 50.4%) of the 657 evaluable medication conversions with complete cost information available. For these 331 conversions, the overall projected MCA overestimated the actual MCA by 14.1% ($24,888 in aggregate or an average of $75 per conversion, P < 0.001). For persistent medication conversions with complete cost information (n = 278), the projected MCA ($160,225) was not significantly different compared with the actual MCA ($166,546, P = 0.477). For medication conversions that reverted to previous therapy (n = 53), the projected MCA ($41,644) overestimated by 4-fold the actual MCA ($10,435, P < 0.001). There were no emergency department visits or hospital admissions related to nonpersistent medication conversions. Compared with patients who were either nonpersistent or disenrolled at the 12-month follow-up, persistent patients did not significantly differ in chronic disease score but were slightly older (mean = 62.6 years, standard deviation = 13.1 for persistent patients vs. 59.2 [SD = 15.5] for nonpersistent or disenrolled patients). CONCLUSIONS: Projected medication cost avoidance for pharmacistinitiated medication conversions is valid for the 66% of medication conversions that persist but not for nonpersistent conversions or for patients who leave the health care system. The projected medication cost avoidance overestimated the actual cost avoidance by approximately 14%, suggesting that there is opportunity for improvement in the tool used to document medication conversions to more accurately measure cost outcomes from clinical pharmacy interventions.