Research Article
Factors Influencing Enrollment in the Medication Therapy Management Clinic at an Academic Ambulatory Care Clinic
Journal of Pharmacy Practice 1-4 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014544791 jpp.sagepub.com
Mansi Shah, PharmD, BCACP, CDE1, Jessica Tilton, PharmD, BCACP1, and Shiyun Kim, PharmD, BCACP, CDE1
Abstract Purpose: In 2001, the University of Illinois Hospital and Health Sciences System (UI Health) established a pharmacist-run, referral-based medication therapy management clinic (MTMC). Referrals are obtained from any UI Health provider or by self-referral. Although there is a high volume of referrals, a large percentage of patients do not enroll. This study was designed to determine the various factors that influence patient enrollment in the MTMC. Methods: This study was a retrospective chart review of demographic and patient variable data during years 2010 and 2011. Disabilities, distance from MTMC, mode of transportation, past medical history, and appointment dates were extracted from the medical records. Results were analyzed using descriptive statistics and logistic regression analysis. Results: A total of 103 referrals were made; however, only 17% of patients remain enrolled in MTMC. The baseline demographics included a mean age of 63 years, 68% female, 70% African American, and 81% English speaking. Patients lived an average of 8 miles from MTMC; most utilized public or government-supplemented transport services; 24% of patients reported some type of disability, most commonly utilizing a walker or a wheelchair. On average, patients were prescribed 13 medications with hypertension (70%), diabetes (56%), and hyperlipidemia (48%) being the most common chronic disease states. The reason for referral included medication management, education, medication reconciliation, and disease state management. Five patients were unable to be contacted to schedule an initial appointment. Additionally, 18 patients failed their scheduled initial appointment and did not reschedule. Logistic regression analysis demonstrated distance traveled for clinic visit, age, and history of hypertension affected the probability of patients showing for their appointments (chi-square ¼ 19.7, P < .001). Conclusion: This study demonstrated that distance from MTMC is the most common barrier in patient enrollment; therefore, strategies to improve patient access are necessary. Keywords ambulatory care, medication therapy management
Medication nonadherence is the fourth leading cause of death in the United States and nonadherence to cardiovascular medications results in approximately 125 000 deaths annually.1 Medication-related problems and poor medication management result in US $177 billion in injury and death resulting from approximately 1.5 million preventable adverse events each year.2 In 2003, the national annual costs of preventable adverse drug effects in Medicare enrollees were estimated to be US $887 million; moreover, the US Pharmacopoeia reported that 35% of medication errors involve older adults.3 In that same year, the Medicare Prescription Drug Improvement and Modernization Act required insurers to provide Medication Therapy Management (MTM) services to a defined subset of beneficiaries. The goals of this provision included improving medication adherence, detecting adverse events and improper medication use, and providing medication education.4 Over the years, many programs have been developed to provide MTM services. MTM services have demonstrated a positive impact
on a variety of factors, including an increase in medication adherence and a reduction in adverse drug events.5-8 It has shown to improve clinical outcomes such as reduction in hemoglobin A1c, blood pressure, and low-density lipoprotein along with a decrease in hospitalizations and emergency department visits.8-13 Although MTM services have proven to be beneficial, not all eligible patients choose to enroll. The use of MTM services by Medicare beneficiaries is voluntary and many choose to opt out. In 2008, only 57% of patients eligible for MTM used the service when offered.14 The Iowa Priority Prescription Savings Program offered MTM services including a
1
University of Illinois at Chicago, Chicago, IL, USA
Corresponding Author: Mansi Shah, University Of Illinois, 1801 W. Taylor St., Chicago, IL 60626, USA. Email: [email protected]
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
2
Journal of Pharmacy Practice
comprehensive medication review at no charge to the patient; however, less than 13% of members obtained the service.15 Current literature has not yet evaluated the factors that influence patient enrollment in MTM services offered at an academic institution. The University of Illinois Hospital and Health Sciences System (UI Health) pharmacist-run medication therapy management clinic (MTMC) has been providing medication and disease state management since 2001. The mission of the MTMC is to provide the best patient care through reconciling and optimizing patient medication regimens, preventing and monitoring for adverse drug events, improving medication adherence, promoting preventative care, collaborating with health care providers to manage disease states, and reducing medication costs. The clinical services have evolved into a comprehensive program that provides 5 distinct areas of service: access, adherence, coordination of care, medication therapy review, and education. All services are free of charge to the patient. The clinic is currently providing MTM services to approximately 150 patients. There are currently 3 pharmacists solely dedicated to the MTMC along with 4 additional pharmacists that divide their time between MTMC and other clinics. Furthermore, there is clinical manager, operations manager, 1 full-time pharmacy technician, 1 student extern, and several pharmacy students who assist with ancillary activities. MTMC is a rotation site for postgraduate year PGY 1 and PGY2 residents and fourth-year pharmacy students. The clinic is embedded in the Outpatient Care Center pharmacy, enabling complete oversight of what medications the patient is receiving on a monthly basis and in the same building as all the other outpatient clinics. This model of MTMC allows for optimization of patient care via continuous collaboration with the patient’s other health care providers.16 Unlike Medicare MTM, the MTMC at UI Health is a noninsurance-driven, referral-based clinic. Referrals are placed by any health care provider at UI Health or self-referred by the patient. Referral forms can be hand delivered, sent via a pneumatic tube, or called into the MTMC. Once the MTM pharmacist obtains the referral form, the patient is scheduled for a 60-minute initial appointment within the following 2 weeks. Although many providers refer patients to the clinic, a high percentage refuse enrollment. This study was designed to determine the various factors that influence patient enrollment in the MTMC at UI Health. Secondary objectives include identifying the most common reasons for referral and evaluating barriers and methods to improve enrollment in the MTMC.
Methods This was a retrospective study reviewing all UI Health MTM referral forms during 2010 and 2011. All paper referral forms were used to collect demographic information such as age, gender, and ethnicity. Furthermore, information on which clinic referred the patient to MTMC, reason for referral, and the time lapse between date of referral, scheduled appointment, and actual appointment was also collected from the referral form.
Table 1. Demographic Information. Characteristic
Percentage (n ¼ 103)
Gender Female Male Ethnicity African American Hispanic Caucasian Others Mode of transportation Public Government Drives car Family member drives Past medical history Hypertension Diabetes Hyperlipidemia Asthma/COPD
68 32 70 12 2 16 33 33 17 17 70 56 48 26
Abbreviation: COPD, chronic obstructive pulmonary disease.
The electronic medical record was accessed to collect information on the distance to which the patient lived from clinic, mode of transportation utilized by the patient, disabilities, past medical history, and number of active medications. All results were analyzed using descriptive statistics and logistic regression analysis.
Results Over the course of 2 years, there were a total of 103 referrals received by the MTMC. The baseline demographics (Table 1) of patients referred to the MTMC showed a mean age of 63 years, with a majority of patients being female (68%), African American (70%), and English speaking (81%). On average, patients lived approximately 8 miles away from the MTMC and most utilized public transportation or government-supplemented transportation services. Of the patients referred to MTMC, 24% reported some type of disability, most commonly requiring a walker or wheelchair. The most common chronic disease states that patients were diagnosed with included hypertension (70%), diabetes (56%), and hyperlipidemia (48%). On average, patients were receiving 13 medications. Based on the analysis of the referral forms, most patients were referred to the MTMC by general medicine (54%) and cardiology (22%). The most common reasons for referral included medication management, education, medication reconciliation, and disease state management (Figure 1). Of the 103 referrals placed, 5 patients did not schedule an initial visit either because they refused enrollment or because the MTMC was unable to contact the patient. Of the 98 patients who scheduled an initial appointment, 18 did not arrive to their initial appointment and did not schedule a follow-up appointment thereafter. Of all the patients referred in 2010 and 2011, approximately 17% remain enrolled in MTMC currently. Patients were discharged from the clinic secondary to multiple
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
Shah et al
3
Medication Management Adherence 4% 13%
6%
40%
16% 21%
Disease State Management DM Management HTN Management Asthma Management
Figure 1. Reason for referral. Table 2. Factors Affecting Enrollment. Inability to contact patients Multiple failed appointments Refusal of transferring care Transportation problems Age Distance traveled from clinic visit History of hypertension
MTM services. They also concluded the demand by older adults for these services appears limited by access to pharmacies that promote the service.17 This study was conducted in a single academic institution which limited the number of patients evaluated thereby reducing the sample size and included only 2 years of data. Furthermore, the MTMC is located within the same building as many outpatient physician providers allowing patients to have easier access to the MTM services and, therefore, cannot be extrapolated to other settings. Despite the clinic being in close proximity to the patient’s health care providers, there were only 103 referrals to the MTMC with over 800 patients seen in the Outpatient Care Center. However, only the most severely ill patients are referred to MTMC. Efforts to improve marketing and the referral process are currently being worked on. Finally, the study results are limited as this clinic mostly serves a Medicare and Medicaid population, thus resources for transportation and even medications may be limited.
Conclusion
failed appointments, inability to contact the patient, refusal of transferring care, or transportation barriers. Logistic regression analysis evaluated the ability of demographic and healthrelated variables to predict the probability of patients showing for their appointments. The final model incorporated distance traveled for clinic visit, history of hypertension, and age as predictors (chi-square ¼ 19.7, P < .001). A stepwise backward deletion process confirmed the inclusion of the 3 predictors. The Wald test showed that each of the 3 variables significantly (P < .05) contributed to the prediction. The odds of the patients showing for their appointments increased by 1.8-fold when the patients had a history of hypertension and decreased by approximately 5% with a 1-year decrease in age or 1-mile increase in distance traveled to their clinic appointment (Table 2).
Discussion This study demonstrates that despite health care providers finding patient benefit in MTMC, there are many barriers that prevent patients from obtaining these services. The primary reasons for nonenrollment or continuing care in the clinic were transportation barriers or inability to contact the patient. Patient participation in MTM programs is voluntary, but there are limited data describing which ‘‘qualified’’ patients will engage and remain actively engaged. The findings of this study gave insight on the predictability of particular patient population in an academic institution; patients who lived closer to the clinic, older, or had a history of hypertension. Similarly, Brooks and colleagues found older adults at higher risk of complications from their prescriptions were more likely to demand
This study demonstrated that providers at UI Health refer a multitude of patients for medication therapy and disease state management signifying the significant role of the pharmacist within the patient’s health care team. Factors that influenced patient enrollment included distance from clinic, age, and presence of comorbidities. Multiple failed appointments, inability to contact the patient, and transportation issues were the most common barriers for patients to enroll in the clinic. Therefore, patient access to services provided by MTM may be potentially improved by placing pharmacists in a patient-centered medical home in order to allow pharmacists to provide services to patients alongside the physician to decrease appointment dates and transportation barriers. Furthermore, conducting initial visits the same day as date of referral would capture more patients to prevent loss to follow-up since the patient is already available in the clinic. Finally, telemedicine or creating a telephonic MTM service would reduce transportation barriers for patients and enable pharmacists to provide services while the patient is in their own home. Overall, the need for MTMC is demonstrated by the large number of referrals; however, strategies to improve patient access are deemed necessary. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. McCarthy R. The price you pay for the drug not taken. Bus Health. 1998;16(10):27-33.
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
4
Journal of Pharmacy Practice
2. American Pharmacists Association. What is medication Therapy Management? www.pharmacist.com/mtm. Accessed December 5, 2013. 3. Field T, Gilman B, Subramanian S, et al. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care. 2005;43(12):1171-1176. 4. Centers for Medicare and Medicaid Services. Fact Sheet: 2013 Medicare Part D Medication Therapy Management (MTM) Programs. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovGenIn/Downloads/Memo-Contract-Year2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf. Accessed December 5, 2013. 5. Murray M, Ritchey M, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. Arch Intern Med. 2009;169(8):757-763. 6. Pindolia V, Stebelsky L, Romain T, et al. Mitigation of medication mishaps via medication therapy management. Ann Pharmacother. 2009;43(4):611-620. 7. Schnipper J, Kirwin J, Cotugno M, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-571. 8. Lee J, Grace K, Taylor A. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and lowdensity lipoprote in cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-2571. 9. Bunting B, Smith B, Sutherland S. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48(1):23-31.
10. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in project ImPACT: hyperlipidemia. J Am Pharm Assoc. 2000;40(2):157-165. 11. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3): 383-391. 12. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008; 48(2):203-211. 13. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized, controlled trial. Arch Intern Med. 2009; 169(9):894-900. 14. American Pharmacists Association. Medication therapy management digest: perspectives on the value of MTM services and their impact on health care. www.pharmacist.com/AM/Template.cfm? Section¼Home2&CONTENTID¼22667&TEMPLATE¼/CM/ ContentDisplay.cfm. Accessed December 5, 2013. 15. Farris K, Ganther-Urmie J, Fang G, et al. Population-based medication reviews: a descriptive analysis of the medication issues identified in a Medicare not-for-profit prescription discount program. Ann Pharmacother. 2004;38(11):1823-1829. 16. Kliethermes M, Schullo-Feulner A, Tilton J, et al. Model for medication therapy management in a university clinic. Am J Health Syst Pharm. 2008;65(9):844-856. 17. Brooks J, Unni E, Klepser D, et al. Factors affecting demand among older adults for medication therapy management services. Res Social Adm Pharm. 2008;4(4):309-319.
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
Factors Influencing Enrollment in the Medication Therapy Management Clinic at an Academic Ambulatory Care Clinic
Journal of Pharmacy Practice 1-4 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014544791 jpp.sagepub.com
Mansi Shah, PharmD, BCACP, CDE1, Jessica Tilton, PharmD, BCACP1, and Shiyun Kim, PharmD, BCACP, CDE1
Abstract Purpose: In 2001, the University of Illinois Hospital and Health Sciences System (UI Health) established a pharmacist-run, referral-based medication therapy management clinic (MTMC). Referrals are obtained from any UI Health provider or by self-referral. Although there is a high volume of referrals, a large percentage of patients do not enroll. This study was designed to determine the various factors that influence patient enrollment in the MTMC. Methods: This study was a retrospective chart review of demographic and patient variable data during years 2010 and 2011. Disabilities, distance from MTMC, mode of transportation, past medical history, and appointment dates were extracted from the medical records. Results were analyzed using descriptive statistics and logistic regression analysis. Results: A total of 103 referrals were made; however, only 17% of patients remain enrolled in MTMC. The baseline demographics included a mean age of 63 years, 68% female, 70% African American, and 81% English speaking. Patients lived an average of 8 miles from MTMC; most utilized public or government-supplemented transport services; 24% of patients reported some type of disability, most commonly utilizing a walker or a wheelchair. On average, patients were prescribed 13 medications with hypertension (70%), diabetes (56%), and hyperlipidemia (48%) being the most common chronic disease states. The reason for referral included medication management, education, medication reconciliation, and disease state management. Five patients were unable to be contacted to schedule an initial appointment. Additionally, 18 patients failed their scheduled initial appointment and did not reschedule. Logistic regression analysis demonstrated distance traveled for clinic visit, age, and history of hypertension affected the probability of patients showing for their appointments (chi-square ¼ 19.7, P < .001). Conclusion: This study demonstrated that distance from MTMC is the most common barrier in patient enrollment; therefore, strategies to improve patient access are necessary. Keywords ambulatory care, medication therapy management
Medication nonadherence is the fourth leading cause of death in the United States and nonadherence to cardiovascular medications results in approximately 125 000 deaths annually.1 Medication-related problems and poor medication management result in US $177 billion in injury and death resulting from approximately 1.5 million preventable adverse events each year.2 In 2003, the national annual costs of preventable adverse drug effects in Medicare enrollees were estimated to be US $887 million; moreover, the US Pharmacopoeia reported that 35% of medication errors involve older adults.3 In that same year, the Medicare Prescription Drug Improvement and Modernization Act required insurers to provide Medication Therapy Management (MTM) services to a defined subset of beneficiaries. The goals of this provision included improving medication adherence, detecting adverse events and improper medication use, and providing medication education.4 Over the years, many programs have been developed to provide MTM services. MTM services have demonstrated a positive impact
on a variety of factors, including an increase in medication adherence and a reduction in adverse drug events.5-8 It has shown to improve clinical outcomes such as reduction in hemoglobin A1c, blood pressure, and low-density lipoprotein along with a decrease in hospitalizations and emergency department visits.8-13 Although MTM services have proven to be beneficial, not all eligible patients choose to enroll. The use of MTM services by Medicare beneficiaries is voluntary and many choose to opt out. In 2008, only 57% of patients eligible for MTM used the service when offered.14 The Iowa Priority Prescription Savings Program offered MTM services including a
1
University of Illinois at Chicago, Chicago, IL, USA
Corresponding Author: Mansi Shah, University Of Illinois, 1801 W. Taylor St., Chicago, IL 60626, USA. Email: [email protected]
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
2
Journal of Pharmacy Practice
comprehensive medication review at no charge to the patient; however, less than 13% of members obtained the service.15 Current literature has not yet evaluated the factors that influence patient enrollment in MTM services offered at an academic institution. The University of Illinois Hospital and Health Sciences System (UI Health) pharmacist-run medication therapy management clinic (MTMC) has been providing medication and disease state management since 2001. The mission of the MTMC is to provide the best patient care through reconciling and optimizing patient medication regimens, preventing and monitoring for adverse drug events, improving medication adherence, promoting preventative care, collaborating with health care providers to manage disease states, and reducing medication costs. The clinical services have evolved into a comprehensive program that provides 5 distinct areas of service: access, adherence, coordination of care, medication therapy review, and education. All services are free of charge to the patient. The clinic is currently providing MTM services to approximately 150 patients. There are currently 3 pharmacists solely dedicated to the MTMC along with 4 additional pharmacists that divide their time between MTMC and other clinics. Furthermore, there is clinical manager, operations manager, 1 full-time pharmacy technician, 1 student extern, and several pharmacy students who assist with ancillary activities. MTMC is a rotation site for postgraduate year PGY 1 and PGY2 residents and fourth-year pharmacy students. The clinic is embedded in the Outpatient Care Center pharmacy, enabling complete oversight of what medications the patient is receiving on a monthly basis and in the same building as all the other outpatient clinics. This model of MTMC allows for optimization of patient care via continuous collaboration with the patient’s other health care providers.16 Unlike Medicare MTM, the MTMC at UI Health is a noninsurance-driven, referral-based clinic. Referrals are placed by any health care provider at UI Health or self-referred by the patient. Referral forms can be hand delivered, sent via a pneumatic tube, or called into the MTMC. Once the MTM pharmacist obtains the referral form, the patient is scheduled for a 60-minute initial appointment within the following 2 weeks. Although many providers refer patients to the clinic, a high percentage refuse enrollment. This study was designed to determine the various factors that influence patient enrollment in the MTMC at UI Health. Secondary objectives include identifying the most common reasons for referral and evaluating barriers and methods to improve enrollment in the MTMC.
Methods This was a retrospective study reviewing all UI Health MTM referral forms during 2010 and 2011. All paper referral forms were used to collect demographic information such as age, gender, and ethnicity. Furthermore, information on which clinic referred the patient to MTMC, reason for referral, and the time lapse between date of referral, scheduled appointment, and actual appointment was also collected from the referral form.
Table 1. Demographic Information. Characteristic
Percentage (n ¼ 103)
Gender Female Male Ethnicity African American Hispanic Caucasian Others Mode of transportation Public Government Drives car Family member drives Past medical history Hypertension Diabetes Hyperlipidemia Asthma/COPD
68 32 70 12 2 16 33 33 17 17 70 56 48 26
Abbreviation: COPD, chronic obstructive pulmonary disease.
The electronic medical record was accessed to collect information on the distance to which the patient lived from clinic, mode of transportation utilized by the patient, disabilities, past medical history, and number of active medications. All results were analyzed using descriptive statistics and logistic regression analysis.
Results Over the course of 2 years, there were a total of 103 referrals received by the MTMC. The baseline demographics (Table 1) of patients referred to the MTMC showed a mean age of 63 years, with a majority of patients being female (68%), African American (70%), and English speaking (81%). On average, patients lived approximately 8 miles away from the MTMC and most utilized public transportation or government-supplemented transportation services. Of the patients referred to MTMC, 24% reported some type of disability, most commonly requiring a walker or wheelchair. The most common chronic disease states that patients were diagnosed with included hypertension (70%), diabetes (56%), and hyperlipidemia (48%). On average, patients were receiving 13 medications. Based on the analysis of the referral forms, most patients were referred to the MTMC by general medicine (54%) and cardiology (22%). The most common reasons for referral included medication management, education, medication reconciliation, and disease state management (Figure 1). Of the 103 referrals placed, 5 patients did not schedule an initial visit either because they refused enrollment or because the MTMC was unable to contact the patient. Of the 98 patients who scheduled an initial appointment, 18 did not arrive to their initial appointment and did not schedule a follow-up appointment thereafter. Of all the patients referred in 2010 and 2011, approximately 17% remain enrolled in MTMC currently. Patients were discharged from the clinic secondary to multiple
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
Shah et al
3
Medication Management Adherence 4% 13%
6%
40%
16% 21%
Disease State Management DM Management HTN Management Asthma Management
Figure 1. Reason for referral. Table 2. Factors Affecting Enrollment. Inability to contact patients Multiple failed appointments Refusal of transferring care Transportation problems Age Distance traveled from clinic visit History of hypertension
MTM services. They also concluded the demand by older adults for these services appears limited by access to pharmacies that promote the service.17 This study was conducted in a single academic institution which limited the number of patients evaluated thereby reducing the sample size and included only 2 years of data. Furthermore, the MTMC is located within the same building as many outpatient physician providers allowing patients to have easier access to the MTM services and, therefore, cannot be extrapolated to other settings. Despite the clinic being in close proximity to the patient’s health care providers, there were only 103 referrals to the MTMC with over 800 patients seen in the Outpatient Care Center. However, only the most severely ill patients are referred to MTMC. Efforts to improve marketing and the referral process are currently being worked on. Finally, the study results are limited as this clinic mostly serves a Medicare and Medicaid population, thus resources for transportation and even medications may be limited.
Conclusion
failed appointments, inability to contact the patient, refusal of transferring care, or transportation barriers. Logistic regression analysis evaluated the ability of demographic and healthrelated variables to predict the probability of patients showing for their appointments. The final model incorporated distance traveled for clinic visit, history of hypertension, and age as predictors (chi-square ¼ 19.7, P < .001). A stepwise backward deletion process confirmed the inclusion of the 3 predictors. The Wald test showed that each of the 3 variables significantly (P < .05) contributed to the prediction. The odds of the patients showing for their appointments increased by 1.8-fold when the patients had a history of hypertension and decreased by approximately 5% with a 1-year decrease in age or 1-mile increase in distance traveled to their clinic appointment (Table 2).
Discussion This study demonstrates that despite health care providers finding patient benefit in MTMC, there are many barriers that prevent patients from obtaining these services. The primary reasons for nonenrollment or continuing care in the clinic were transportation barriers or inability to contact the patient. Patient participation in MTM programs is voluntary, but there are limited data describing which ‘‘qualified’’ patients will engage and remain actively engaged. The findings of this study gave insight on the predictability of particular patient population in an academic institution; patients who lived closer to the clinic, older, or had a history of hypertension. Similarly, Brooks and colleagues found older adults at higher risk of complications from their prescriptions were more likely to demand
This study demonstrated that providers at UI Health refer a multitude of patients for medication therapy and disease state management signifying the significant role of the pharmacist within the patient’s health care team. Factors that influenced patient enrollment included distance from clinic, age, and presence of comorbidities. Multiple failed appointments, inability to contact the patient, and transportation issues were the most common barriers for patients to enroll in the clinic. Therefore, patient access to services provided by MTM may be potentially improved by placing pharmacists in a patient-centered medical home in order to allow pharmacists to provide services to patients alongside the physician to decrease appointment dates and transportation barriers. Furthermore, conducting initial visits the same day as date of referral would capture more patients to prevent loss to follow-up since the patient is already available in the clinic. Finally, telemedicine or creating a telephonic MTM service would reduce transportation barriers for patients and enable pharmacists to provide services while the patient is in their own home. Overall, the need for MTMC is demonstrated by the large number of referrals; however, strategies to improve patient access are deemed necessary. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. McCarthy R. The price you pay for the drug not taken. Bus Health. 1998;16(10):27-33.
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
4
Journal of Pharmacy Practice
2. American Pharmacists Association. What is medication Therapy Management? www.pharmacist.com/mtm. Accessed December 5, 2013. 3. Field T, Gilman B, Subramanian S, et al. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care. 2005;43(12):1171-1176. 4. Centers for Medicare and Medicaid Services. Fact Sheet: 2013 Medicare Part D Medication Therapy Management (MTM) Programs. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovGenIn/Downloads/Memo-Contract-Year2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf. Accessed December 5, 2013. 5. Murray M, Ritchey M, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. Arch Intern Med. 2009;169(8):757-763. 6. Pindolia V, Stebelsky L, Romain T, et al. Mitigation of medication mishaps via medication therapy management. Ann Pharmacother. 2009;43(4):611-620. 7. Schnipper J, Kirwin J, Cotugno M, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-571. 8. Lee J, Grace K, Taylor A. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and lowdensity lipoprote in cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-2571. 9. Bunting B, Smith B, Sutherland S. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48(1):23-31.
10. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in project ImPACT: hyperlipidemia. J Am Pharm Assoc. 2000;40(2):157-165. 11. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3): 383-391. 12. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008; 48(2):203-211. 13. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized, controlled trial. Arch Intern Med. 2009; 169(9):894-900. 14. American Pharmacists Association. Medication therapy management digest: perspectives on the value of MTM services and their impact on health care. www.pharmacist.com/AM/Template.cfm? Section¼Home2&CONTENTID¼22667&TEMPLATE¼/CM/ ContentDisplay.cfm. Accessed December 5, 2013. 15. Farris K, Ganther-Urmie J, Fang G, et al. Population-based medication reviews: a descriptive analysis of the medication issues identified in a Medicare not-for-profit prescription discount program. Ann Pharmacother. 2004;38(11):1823-1829. 16. Kliethermes M, Schullo-Feulner A, Tilton J, et al. Model for medication therapy management in a university clinic. Am J Health Syst Pharm. 2008;65(9):844-856. 17. Brooks J, Unni E, Klepser D, et al. Factors affecting demand among older adults for medication therapy management services. Res Social Adm Pharm. 2008;4(4):309-319.
Downloaded from jpp.sagepub.com at UNIV CALIFORNIA SAN DIEGO on November 14, 2015
