506883

research-article2013

AOPXXX10.1177/1060028013506883Annals of PharmacotherapyFranklin et al

Research Report

Pharmacoeconomic Analysis of the Diabetes Initiative Program: A Pharmacist-Physician Collaborative Care Model

Annals of Pharmacotherapy 47(12) 1627­–1634 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013506883 aop.sagepub.com

Brandi E. Franklin, PhD, MBA1, Michelle Z. Farland, PharmD2, Jeremy Thomas, PharmD3, M. Shawn McFarland, PharmD4, Shaunta’ M. Ray, PharmD2, and Debbie C. Byrd, PharmD2

Abstract Background: Diabetes treatment cost increased 41% from 2007 to 2011. Pharmacists have provided collaborative diabetes management for decades with improvement in disease-related end points. Few have reported economic benefits of pharmacist management of type 2 diabetes. Objective: The purpose was to determine if cost savings associated with hemoglobin A1c (A1C) and systolic blood pressure (SBP) change outweighed programmatic pharmacist-physician collaborative care model costs. Methods: This cost analysis of a 12 month, prospective, multicenter, observational study included English-speaking adults, 18 years or older, with type 2 diabetes mellitus, a life expectancy >1 year, and either a A1C >7%, SBP >130 mm Hg, diastolic blood pressure >80 mm Hg, or low-density lipoprotein concentration >100 mg/dL. Pregnant patients were excluded. Primary analysis outcome was average cost per outcome, ratio of net cost (numerator) and percentage achieving outcomes (denominator). Assessment outcomes included A1C reduction by at least 1% and SBP reduction by at least 5.6 mm Hg. Results: 206 patients were seen by pharmacists during 1612 encounters (mean = 7.8 encounters/patient). Pharmacists spent 983 hours caring for type 2 diabetes patients (mean 3.8 hours/patient). Base case net labor and program costs per patient were −$66.77 and $106.81, respectively. Improvement in A1C and SBP yielded $421.01 in cost savings per patient. Labor and program average costs per patient for each outcome achieved were −$100.40 and $160.61, respectively. Conclusions: This multisite pharmacist-physician collaboration in diabetes management showed cost savings when assessing pharmacist labor costs alone. Total program costs, including overhead, slightly increased cost of care. Keywords diabetes, collaborative care, pharmacoeconomics, pharmacist, clinical pharmacy

Introduction Nearly 26 million Americans are afflicted with diabetes. This prevalence accounts for more than 8% of the United States population, and that number is on the rise. Along with the incidence of diabetes, the cost of treatment has risen consistently as well, up 41% from $174 billion in 2007 to $245 billion in 2011. Approximately one-third of this is spent on prescription medications, including antidiabetic agents and diabetic supplies.1 These costs are undoubtedly greater in cases where diabetes is not adequately managed. Dietary constraints, administration, and monitoring of multiple medications and risk management of other comorbid conditions can make diabetes potentially very difficult

to manage. It requires vigilance from both patients and caregivers alike. The high economic burden coupled with 1

University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA 2 University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA 3 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA 4 Department of Veterans Affairs Medical Center, Nashville, TN, USA Corresponding Author: Michelle Z. Farland, Department of Clinical Pharmacy, University of Tennessee Health Science Center College of Pharmacy, Knoxville Campus, 1924 Alcoa Highway, Box 117, Knoxville, TN 37920, USA. Email: [email protected]

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the complicated management of diabetes makes these patients ideal candidates for pharmacist intervention. Multiple studies have assessed the financial and qualityof-life impact of pharmacist interventions or pharmacistphysician collaborative management in patients with diabetes. In most cases, the quality of life improved, and the cost of treatment either stayed the same or decreased.2,3 Diabetes management by pharmacists has been shown to significantly improve the hemoglobin A1c (A1C) value.4 Few studies have been conducted to assess the economic impact of clinical services provided by pharmacists in this patient population.5 The purpose of this study was to determine if cost savings associated with change in A1C and systolic blood pressure (SBP) outweighed the programmatic costs of a pharmacist-physician collaborative care model.

Methods Study Design This cost analysis is based on a prospective observational study to determine the impact of pharmacist-physician collaborative care for patients with type 2 diabetes mellitus on clinical outcomes.6 The study was conducted at 7 primary care practices across the state. Patients were enrolled from December 2008 through October 2010 and were followed for 12 months. The study was approved by the institutional review board at the University of Tennessee Health Science Center, Graduate School of Medicine, and the Veterans Affairs Hospital.

Patient Population Patients included were English-speaking adults, 18 years or older, with type 2 diabetes mellitus, a life expectancy greater than 1 year, and either a A1C >7%, SBP >130 mm Hg, diastolic blood pressure >80 mm Hg, or low-density lipoprotein concentration >100 mg/dL. Pregnant patients were excluded. The study followed an intention-to-treat method. All patients who had at least 1 appointment with a pharmacist and consented to be enrolled in the study were included in the analysis with last value carried forward.

Clinical Intervention Details of the intervention have been described elsewhere.6 Briefly, patients were enrolled in a collaborative care model with clinical pharmacists and physicians. The collaborative method could include (1) a collaborative practice agreement; (2) appointments scheduled for patients to see both a pharmacist and a nurse practitioner or physician; and (3) patient appointments with a pharmacist who reviewed each case with a physician to develop a treatment plan. Follow-up visits were scheduled as clinically necessary, with time

intervals ranging from 1 to 12 weeks. Follow-up visits were conducted face-to-face or via telephone. The role of pharmacists in the collaborative care model included medication therapy management (MTM) to initiate, adjust, or discontinue medications for type 2 diabetes mellitus, hypertension, and dyslipidemia; patient education; review of self-monitored blood glucose records; ordering and monitoring of laboratory tests; performing sensory foot exams; referring patients for dilated retinal exams; and ordering or recommending immunizations.

Measures The pharmacists at each site were responsible for recording all patient-related activities that occurred at every encounter during the study period. At each patient encounter, the pharmacist documented the type(s) of intervention provided, patient-reported and clinician-reported barriers to glycemic goal achievement, visit type (pharmacist only or pharmacist-physician), method of visit (face-to-face or telephone), and pharmacist-patient visit duration (in 15 minute increments). An encounter could include one or more types of interventions. The minimum duration recorded for an encounter was 15 minutes. This time increment reflects current billing practices for delivery of pharmacist-provided MTM services.7 Pharmacists did not bill for MTM services in this study. Any encounter lasting longer than 90 minutes was recorded as 90 minutes. Only 2 encounters exceeded that duration. Neither activities completed before or after a pharmacist-patient encounter nor physician, nurse practitioner, and physician assistant–patient contact time were recorded for analysis.

Statistical Analyses Data were analyzed using SAS 9.3 (SAS Institute Inc, Cary, NC). Descriptive statistics were used to summarize pharmacist-patient contact time for each encounter or visit as well as achievement of A1C and blood pressure goals. A multiple imputation technique was used to estimate visit duration for 117 pharmacist-patient encounters with missing visit duration data. Cost analysis was conducted from the perspective of an academic medical institution. This method of evaluation was chosen because of the absence of a comparator population. Labor costs were calculated using pharmacist salary and fringe benefits estimates, adjusted by an efficiency ratio. Mean hourly wage data in the year 2011 were obtained for pharmacists practicing in Tennessee from the United States Bureau of Labor Statistics ($55.51 per hour with a sensitivity range of $48.73-$62.17 per hour).8 Fringe benefits were based on those provided by the University of Tennessee Health Science Center (33.79%, with a sensitivity range of 20%-40%). Efficiency estimates, which account for the time devoted to patient care activities

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Franklin et al Table 1.  Summary Statistics for Cohort and Subgroups. Sex

Variable Contact time, minutes Pharmacist-patient encounters, mean A1C

Pharmacoeconomic analysis of the diabetes initiative program: a pharmacist-physician collaborative care model.

Diabetes treatment cost increased 41% from 2007 to 2011. Pharmacists have provided collaborative diabetes management for decades with improvement in d...
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