RESUMEN
OBJECTIVE: To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression. DESIGN: Prospective, nonrandomized, proof-of-concept investigation. SETTING: Asheville, NC, from July 2006 through December 2007. PARTICIPANTS: Employees or adult dependents with depressive symptoms who agreed to enroll in an employer-sponsored treatment program conducted at two ambulatory clinics where consultative services were provided. Participants were included in the analysis if they participated in the program for at least 1 year and had two or more documented visits with a pharmacist. INTERVENTION: Outpatient-based pharmacists provided assessment, self-management services follow-up, and treatment recommendations to primary care providers within a collaborative care management model. MAIN OUTCOME MEASURES: Changes in severity of depressive symptoms and impact on overall health care costs for employers and beneficiaries. RESULTS: Of the 151 beneficiaries referred to the program, 130 (82%) remained under pharmacist care for a minimum of 1 year and were included in the aggregate analysis. Statistically significant improvements were observed for Patient Health Questionnaire (PHQ)-9 scores from baseline to endpoint (11.5 ± 6.6 to 5.3 ± 4.7 [mean ± SD], P < 0.0001). The clinical response rate was 68% with a 56% remission rate. In economic subgroup analysis (n = 48), annual medical costs decreased from an average of $6,351 per enrollee to $5,876, which was lower than the projected value ($7,195). Total health care costs to the employer increased from $7,935 per enrollee to $8,040, which was lower than the projected value ($9,023). CONCLUSION: Patients in the first year of the program had significant improvement in the PHQ-9 clinical indicator of depression severity. Total health care costs per patient per year were reduced compared with projected costs without the program. Employers expressed their appreciation for this collaborative care program and continued to offer this voluntary health benefit after the study's conclusion.
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Antidepresivos/economía , Antidepresivos/uso terapéutico , Depresión/tratamiento farmacológico , Depresión/economía , Costos de la Atención en Salud , Servicios Farmacéuticos/economía , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , North Carolina , Proyectos PilotoRESUMEN
BACKGROUND: The results of the Asheville Project have shown the success of a community-based, chronic disease management model in improving clinical outcomes in patients with chronic disease while reducing annual costs of care per participant. The question arose whether other programs using a similar management model and implemented in other communities could replicate the success of the Asheville Project in improving clinical outcomes and reducing costs for patients with a chronic disease. OBJECTIVE: To assess the long-term clinical and financial outcomes of a chronic care management model for patients with diabetes, using the Asheville care management model that was successful in the management of several chronic diseases. STUDY DESIGN: Longitudinal, 3-year (2007-2009), quasi-experimental, multisite, pre-/postenrollment study. METHODS: Self-insured health plan members with diabetes agreed to meet on a regular basis (ie, an average of every 3 months) with a healthcare professional. Participants received reduced copayments on diabetes-related medications and supplies as an incentive for participating in the study. Providers utilized a web-based electronic medical record system that provided updated medical and prescription data and highlighted gaps in care based on national standards. Program providers included community pharmacists, population health management company pharmacists, and nurses at on-site clinics, trained in use of evidence-based guidelines of care. Providers assessed patients' medications, knowledge level, and lifestyle; provided patient education and goal setting; and referred patients for physician follow-up and recommendations to physicians. The majority of the encounters were face-to-face. RESULTS: The study included 95 plan members in the clinical cohort participating for 1 year or more, and 54 members in the financial cohort who have been participating in the program for 3 years. At the end of 3 years, the percentages of those achieving guideline goals increased from baseline to the latest follow-up included, respectively, reaching target hemoglobin A1c levels, 38% to 53%; low-density lipoprotein cholesterol, 46% to 67%; systolic blood pressure (BP), 55% to 72%; diastolic BP, 60% to 71%; annual eye examination, 37% to 61%; and self-testing blood glucose, 79% to 97%. Total healthcare costs decreased by an average of $2704 per participant per year. The program's return on investment was $4.89 to every $1 spent (including program costs). CONCLUSION: The Hickory Project shows that it is possible to produce sustained improvements in clinical outcomes and reductions in healthcare costs for patients with diabetes using a chronic care model that provides frequent patient follow-up, a focus on appropriate medication therapy, adherence to clinical practice guidelines, and a reduction in prescription copayments for antidiabetes medications as an incentive for patients to participate in the program.
RESUMEN
OBJECTIVE: Assess clinical and economic outcomes of a community-based, long-term medication therapy management (MTM) program for hypertension (HTN)/dyslipidemia. DESIGN: Quasi-experimental, longitudinal, pre-post study. SETTING: 12 community and hospital pharmacy clinics in Asheville, N.C., over a 6-year period from 2000 through 2005. PARTICIPANTS: Patients covered by two self-insured health plans; educators at Mission Hospitals; 18 certificate-trained pharmacists. INTERVENTIONS: Cardiovascular or cerebrovascular (collectively abbreviated as CV) risk reduction education; regular, long-term follow-up by pharmacists (reimbursed by health plans) using scheduled consultations, monitoring, and recommendations to physicians. MAIN OUTCOME MEASURES: Clinical and economic parameters. RESULTS: Sufficient data were available for 620 patients in the financial cohort and 565 patients in clinical cohort. Several indicators of cardiovascular health improved over the course of the study: mean systolic blood pressure, from 137.3 to 126.3 mm Hg; mean diastolic blood pressure, from 82.6 to 77.8 mm Hg; percentage of patients at blood pressure goal, from 40.2% to 67.4%; mean low-density lipoprotein (LDL) cholesterol, from 127.2 to 108.3 mg/dL; percentage of patients at LDL cholesterol goal, from 49.9% to 74.6%; mean total cholesterol, from 211.4 to 184.3 mg/dL; and mean serum triglycerides, from 192.8 to 154.4 mg/dL. Mean high-density lipoprotein (HDL) cholesterol decreased from 48 to 46.6 mg/dL. The CV event rate during the historical period, 77 per 1,000 person-years, declined by almost one-half (38 per 1,000 person-years) during the study period. Mean cost per CV event in the study period was $9,931, compared with $14,343 during the historical period. During the study period, CV medication use increased nearly threefold, but CV-related medical costs decreased by 46.5%. CV-related medical costs decreased from 30.6% of total health care costs to 19%. A 53% decrease in risk of a CV event and greater than 50% decrease in risk of a CV-related emergency department (ED)/hospital visit were also observed. CONCLUSION: Patients with HTN and/or dyslipidemia receiving education and long-term MTM services achieved significant clinical improvements that were sustained for as long as 6 years, a significant increase in the use of CV medications, and a decrease in CV events and related medical costs.
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Servicios Comunitarios de Farmacia/organización & administración , Dislipidemias/tratamiento farmacológico , Costos de la Atención en Salud , Hipertensión/tratamiento farmacológico , Administración del Tratamiento Farmacológico , Adolescente , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/prevención & control , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/prevención & control , Estudios de Cohortes , Dislipidemias/complicaciones , Dislipidemias/economía , Femenino , Humanos , Hipertensión/complicaciones , Hipertensión/economía , Lípidos/sangre , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto , Farmacéuticos , Rol Profesional , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years. DESIGN: Quasi-experimental, longitudinal pre-post study. SETTING: 12 pharmacy locations in Asheville, N.C. PATIENTS/OTHER PARTICIPANTS: Patients with asthma covered by two self-insured health plans; professional educator at Mission Hospitals; 18 certificate-trained community and hospital pharmacists. INTERVENTIONS: Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians. MAIN OUTCOME MEASURES: Changes in forced expiratory volume in 1 second (FEV1), asthma severity, symptom frequency, the degree to which asthma affected people's lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time. RESULTS: All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population's historical trends. Direct cost savings averaged 725 dollars/patient/year, and indirect cost savings were estimated to be 1230 dollars/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions. CONCLUSION: Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.
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Asma/tratamiento farmacológico , Servicios Comunitarios de Farmacia/organización & administración , Costos de la Atención en Salud , Humanismo , Absentismo , Adulto , Asma/economía , Asma/psicología , Servicios Comunitarios de Farmacia/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , North Carolina , Calidad de Vida , Índice de Severidad de la EnfermedadRESUMEN
Research into the impact of pharmaceutical care need not be complex, but it is difficult in real-world settings. Pharmaceutical care projects need a committed project manager, dedicated pharmacists, an involved payer, and patients who believe they have a problem that needs to be addressed. Significant differences in outcomes are more likely with some chronic diseases than with others. Adequate funding of pharmaceutical care studies is needed to support identification of drug-related problems and outcomes in larger numbers of patients and over longer time periods. Demonstrating changes in patient satisfaction with providers and in health-related quality of life is difficult.
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Investigación sobre Servicios de Salud , Servicios Farmacéuticos/normas , Educación del Paciente como Asunto , Servicios Farmacéuticos/provisión & distribuciónRESUMEN
OBJECTIVE: To assess the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services (PCS) for patients with diabetes. DESIGN: Quasi-experimental, longitudinal pre-post cohort study. SETTING: Twelve community pharmacies in Asheville, N.C. PATIENTS AND OTHER PARTICIPANTS: Patients with diabetes covered by self-insured employers' health plans. Community pharmacists trained in a diabetes certificate program and reimbursed for PCS. INTERVENTIONS: Education by certified diabetes educators, long-term community pharmacist follow-up using scheduled consultations, clinical assessment, goal setting, monitoring, and collaborative drug therapy management with physicians. MAIN OUTCOME MEASURES: Changes in glycosylated hemoglobin (A1c) and serum lipid concentrations and changes in diabetes-related and total medical utilization and costs over time. RESULTS: Mean A1c decreased at all follow-ups, with more than 50% of patients demonstrating improvements at each time. The number of patients with optimal A1c values (< 7%) also increased at each follow-up. More than 50% showed improvements in lipid levels at every measurement. Multivariate logistic regressions suggested that patients with higher baseline A1c values or higher baseline costs were most likely to improve or have lower costs, respectively. Costs shifted from inpatient and outpatient physician services to prescriptions, which increased significantly at every follow-up. Total mean direct medical costs decreased by $1,200 to $1,872 per patient per year compared with baseline. Days of sick time decreased every year (1997-2001) for one employer group, with estimated increases in productivity estimated at $18,000 annually. CONCLUSION: Patients with diabetes who received ongoing PCS maintained improvement in A1c over time, and employers experienced a decline in mean total direct medical costs.