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Improving Chronic Disease Outcomes Through Pharmacist Care Services

R. William Soller, PhD Professor, UCSF School of Pharmacy Executive Director, Center for Self Care. Improving Chronic Disease Outcomes Through Pharmacist Care Services. Invited Lecturer: International Society for Pharmacoeconomics and Outcomes Research November 19, 2009

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Improving Chronic Disease Outcomes Through Pharmacist Care Services

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  1. R. William Soller, PhD Professor, UCSF School of Pharmacy Executive Director, Center for Self Care Improving Chronic Disease Outcomes Through Pharmacist Care Services Invited Lecturer: International Society for Pharmacoeconomics and Outcomes Research November 19, 2009 Via international conference call UC SF

  2. Outline • Context • Pharmacist Care Services • Definition • Asheville • Center for Self Care • Challenges

  3. ContextMedical Claims by Age Cohorts

  4. ContextChronic Disease Burden: U.S. Seven of every 10 Americans who die each year, or more than 1.7 million people, die of a chronic disease. http://www.cdc.gov/NCCdphp/overview.htm

  5. CONTEXTCDC: We cannot effectively address escalating health care costs without addressing chronic diseases. • >133 MM (~50% Americans), > 1 chronic condition. • Chronic diseases account for: • 70% of all deaths in US • >75% of $2 trillion medical care costs in US • 33% of the years of potential life lost before age 65. • The annual direct and indirect costs • DM $174 billion • Smoking $193 billion • Heart disease and stroke $448 billion • Obesity $117 billion • Cancer $ 89 billion http://www.cdc.gov/NCCdphp/overview.htm

  6. Context • Prevalence of Diabetes in California • 18-44 yr olds 4.3% • 45-64 yr olds 11.8% • 65-79 yr olds 12.4% • For Californians with Diabetes *: • 82% are overweight or obese • 60% have high blood cholesterol • 63% have hypertension • 40% had fewer than 2 HbA1c tests annually • 30% those over 65 did not receive a flu shot • 88% saw a health professional for diabetes • 67% received a dilated eye exam w/in last year • 62% perform daily foot self-exam *most recent data from CDC, 2006

  7. ContextConsequences of Poor Self-Management of Chronic Disease • Diabetes: • Retinopathy • Kidney disease • Microvascular disease – heart attack and stroke • Amputation • High health care costs

  8. DEFINITIONSSelf Care & Pharmacist Care Services (PCS) • “Supported Self Care” for Chronic Disease ManagementAn on-going process that • Facilitates the knowledge, skill, and ability necessary for self-care; • Incorporates the needs, goals, and life experiences of the person; • Is guided by evidence-based standards. • Is distinguished from “self-determined self care” and “facilitated self care.” • The Role of the Pharmacist • Serves as a coach through counseling and supervision of self care • Supports problem-solving, informed decision-making, and behavioral changes by the patient; • Improvesclinical outcomes, health status, and quality of life by making recommendations for appropriate use of medications, nutrition, exercise, and wellness activities; • Facilitatesconnectivity/active collaboration among the health care team. Implications for Industry Patients not meeting standards of care – HEDIS: Improve adherence, presumably if increase adherence, increase sales But, the issue is medication adjustments….Pharma not prepared for this

  9. Asheville ProjectHypertension and Dyslipidemia Bunting B et al. J Am Pharm Assoc. 2008;48:23–31. • Setting • 12 community and hospital pharmacy clinics in Asheville, N.C. • Time Period: 2000 through 2005. • Participants • Patients in 2 self-insured health plans • Educators at Mission Hospitals • 18 certificate-trained pharmacists. • Interventions • CV risk reduction education (cardio- or cerebrovascular) • Regular, long-term follow-up by pharmacists (reimbursed by health plans) • Scheduled consultations • Monitoring • Recommendations to physicians. • Main Outcome Measures • Clinical and economic parameters

  10. Asheville: HTN, Dyslipidemia Bunting B et al. J Am Pharm Assoc. 2008;48:23–31.

  11. Asheville: HTN, Dyslipidemia Bunting B et al. J Am Pharm Assoc. 2008;48:23–31.

  12. Asheville: HTN, Dyslipidemia Bunting B et al. J Am Pharm Assoc. 2008;48:23–31. Outcomes (n=625/financial; n=565/clinical)PrePost • Sys BP (mean) 137.3 126.3 mm Hg; • Dias BP (mean) 82.6 77.8 mm Hg; • % at BP goal40.2 67.4 % • LDL (mean) 127.2 108.3 mg/dL; • % at LDL goal49.9 74.6 % • Total cholesterol, (mean) 211.4 184.3 mg/dL • Serum TG (mean) 192.8 154.4 mg/dL • HDL (mean) 48 46.6 mg/dL • Risk of a CV event - 53 % reduction • CV-related medical costs - 38 % of total health care costs • mean cost/CV event - 30% ($14,343 vs.$9,931) • CV medication use threefold increase • Total medical costs - 46 % • Risk of CV-rel. ED/hosp visits - 50% reduction

  13. Pooled Assessment Perez A et al. Pharmacotherapy 2008:28(11);285e-323c) • Contracted by American College of Clinical Pharmacy (ACCP) • A systematic review of pharmacoeconomic studies relating to pharmacist care services from 2001 through 2005 • 45 studies with economic evaluations (48.4%) • 15 studies with sufficient data to perform a benefit-cost ratio • Main Economic Finding: • Pooled median value of PCS was 4.8:1 • For every dollar invested in CPS, $4.81 was achieved in reduced costs or other economic benefits.

  14. Pooled Assessment Perez A et al. Pharmacotherapy 2008:28(11);285e-323c) • Types of Services (All publications) • General pharmacother. monitoring services 34.4% (32) • Target drug programs 29.1% (27) • Disease state management services 22.6% (21) • Settings (All publications) • Hospitals 43.0% (40) • Ambulatory care clinics or physician’s offices 21.5% (20) • Community pharmacies 17.2% (16)

  15. Benefit to Cost Ratios of Published Economic Evaluations of Clinical Pharmacy Services from Three Periods • For every dollar invested in CPS, • $4.81 was achieved in reduced • costs or other economic benefits. Perez, A. et al. Pharmacotherapy 2008:28(11);285e-323c)

  16. NCPCCChronic Disease Management Programs • Clinical Services • St. Anthony’s Free Medical Clinic • UA Local 447 Pipefitters, members/dependents • Raley’s employees, members/dependents • CalPERS members/dependents • Patients n=150, >500 visits

  17. Community Pharmacy Model of Carefor Chronic Disease Management Community Pharmacists Corporate Pharmacy Services Patients’ PCPS Patients Blue Shield CalPERS Design, Field Ops, Analysis UC SF

  18. Telepharmacy Model of Carefor Chronic Disease Management Benefits Administrator • Scheduling Patients Nurse Educators Tele- Pharmacists UC SF Patients’ PCPS • Counseling • Design • Field Ops • Analysis

  19. Our collaborative has included: • Patients • CalPERS (California Public Employee Retirement System) • Raley’s Employees and their dependents • Union Local 447 (Pipe Trades) members and dependents • St. Anthony’s Free Medical Clinic Patients • Patient Groups • California Chronic Care Coalition • Health Care Providers • Raley’s pharmacists • UCSF pharmacists of the Center for Self Care, UCSF Department of Clinical Pharmacy • Payers • Blue Shield of California • Raley’s Pharmacies • Pharma Companies • Sanofi-Aventis • GlaxoSmithKline • Foundations • Nat’l Assoc. Chain Drug Stores Foundation • The Pharmacy Foundation of California • McKesson Foundation • Researchers • University of California School of Pharmacy Center for Self Care BackgroundPartnership Alignment • The Northern California Pharmacist Care Collaborative (NCPCC) = • Patients • Payers (employers, insurers, unions) • Health Providers (physicians, pharmacists, nurses) • Pharma companies • Foundations • Researchers (universities) • Our Premise • 12 years of mounting evidence shows pharmacist monitoring of chronic care patients is clinically and cost effective.

  20. NCPCC Diabetes Self-management Program

  21. Program Reach • CalPERS-Raley’s-Blue Shield • ~30,000 square miles • Based on zip codes (pt & store) • 48 Raley’s pharmacies • 360 CalPers members • UA Local 447 Sacramento • 150 patients • Multiple chronic diseases • DM • ASM/COPD • HTN • CVD • CHF • Depression • St Anthony Free Medical Clinic • 60 patients with DM • Includes insulin titration RENO Hollister

  22. Patient SatisfactionOverall: 93% satisfied/extremely satisfied Would you recommend this program to a family member of friend? Early return achievable with low numbers n=69 n=39

  23. Pharmacists Recommendations • UA447 Pharmacist Consult Service • Chart review of 96 past visits within 6 week period • December 2008 – February 15, 2009 • 2 clinical pharmacists • Study n = 44 • n = 23 w/DM • n = 21 other chronic conditions and/or polypharmacy (>5 medications) • Parameter • Top three recommendations to patient and/or provider • In some cases < 3 recommendations were made

  24. Pharmacist-Initiated RecommendationsPatients with DiabetesPharmacist-to-PCPPharmacist-to-Patient Tracking RPh Recommendations: Early Return & QA Tool for Expansion

  25. Clinical Outcomes • HbA1c • LDL • Systolic BP • Diastolic BP

  26. Clinical Outcomes 83%, lowered or maintained HbA1c <7% Mean reduction from 8.4% at baseline to 7.1% (p=.0046)

  27. Lerner D et al. The Work Limitations Questionnaire. Medical Care 2001;39:72-85. Lerner D et al. The Work Limitations Questionnaire. Medical Care 2001;39:72-85.

  28. Presenteeism: Raley’s Lerner D et al. The Work Limitations Questionnaire. Medical Care 2001;39:72-85. Workplace Outcomes Are Important to Employers. Lerner D et al. The Work Limitations Questionnaire. Medical Care 2001;39:72-85.

  29. Medical and Pharmacy Claims • RALEY’s (n=25) /6 months • DM-related Medical Claims • Enrollees 41 % decrease • DM-related Rx claims • Enrollees 14% increase • UA447 (n= 23) /6months • Total Medical Claims (DM and ASM) • Enrollees 28% decrease • Non-enrollees 11% increase A Rigorous Program with Defined Protocols and Excellent Field Management Can Demonstrate Positive Clinical Outcomes in 4-6 Months in Relatively Low Numbers of Patients

  30. Issues and Challenges • Soller RW and Vogt E. Defining barriers to Expanded Pharmacist Care Services. International Journal of Pharmacy Practice 17;December 2009. Accepted 11/09“Yet, significant challenges remain on both the market and the profession sides of the equation. These challenges are interlinked and relate to: market awareness of the value of pharmacist services; stakeholder alignment; model sustainability and scalability; data access; program design; and accountability for quality and outcomes.”

  31. Issues and Challenges • Market Awareness of the Value of Pharmacist Services • C-Suite & Credible Underestimates

  32. Our collaborative has included: • Patients • CalPERS (California Public Employee Retirement System) • Raley’s Employees and their dependents • Union Local 447 (Pipe Trades) members and dependents • St. Anthony’s Free Medical Clinic Patients • Patient Groups • California Chronic Care Coalition • Health Care Providers • Raley’s pharmacists • UCSF pharmacists of the Center for Self Care, UCSF Department of Clinical Pharmacy • Payers • Blue Shield of California • Raley’s Pharmacies • Pharma Companies • Sanofi-Aventis • GlaxoSmithKline • Foundations • Nat’l Assoc. Chain Drug Stores Foundation • The Pharmacy Foundation of California • McKesson Foundation • Researchers • University of California School of Pharmacy Center for Self Care Issues and Challenges • The Northern California Pharmacist Care Collaborative (NCPCC) = • Patients • Payers (employers, insurers, unions) • Health Providers (physicians, pharmacists, nurses) • Pharma companies • Foundations • Researchers (universities) • Stakeholder Alignment

  33. Issues and Challenges • Model Sustainability and Scalability • Stereotypic role of pharmacist as dispenser of medicines • Pharmacist Care Services for MTM and Chronic Disease Management: • Multi-visit: 40 min, 20 min • Reimbursement: $2.00/minute (?); $150/visit (?) • Key Questions • Who gets paid – the plan or the pharmacist? • Who does the services – PharmD, RN, tech help? • What is the optimal model? • What model is scalable? • Clinic to Municipality to State to Nation

  34. Issues and Challenges • Data Access -- Evidence is the engine that runs health policy. • Disadvantages of Large Payer Systems • Contractual Arrangements – limit data to aggregate form • Competing Programs • True control a question • Comparator group in context of a Phase IV open label study design • Cost, an issue and related to power calculations if “active vs. active” type comparison • Program Design • Training in research design, an issue in payer/benefits management • E.g.: risk stratification, rolling enrollment, protocol development

  35. Asheville: HTN, Dyslipidemia Bunting B et al. J Am Pharm Assoc. 2008;48:23–31. Outcomes (n=625/financial; n=565/clinical)PrePost • Sys BP (mean) 137.3 126.3 mm Hg; • Dias BP (mean) 82.6 77.8 mm Hg; • % at BP goal40.2 67.4 % • LDL (mean) 127.2 108.3 mg/dL; • % at LDL goal49.9 74.6 % • Total cholesterol, (mean) 211.4 184.3 mg/dL • Serum TG (mean) 192.8 154.4 mg/dL • HDL (mean) 48 46.6 mg/dL • Risk of a CV event - 53 % reduction • CV-related medical costs - 38 % of total health care costs • mean cost/CV event - 30% ($14,343 vs.$9,931) • CV medication use threefold increase • Total medical costs - 46 % • Risk of CV-rel. ED/hosp visits - 50% reduction

  36. Limitations • Regression to the mean • The chance that patients would have improved without program interventions because on average a bad year would be followed by a good year • Steps taken to reduce potential for this type of bias • Historical data • Historical data went back 3 years pre-enrollment, to be sure they didn’t enroll just because they had a bad year • Highest CV event rate was 3 years before enrollment • Lowest CV event rate was the year before enrollment • Follow-up data • 6-years

  37. Issues and Challenges • Accountability for Quality and Outcomes • Access to Data • Type of Data • Adherence vs. Optimal medication utilization

  38. Conclusion • Growing body of evidence support the value of pharmacist care services (PCS), with substantial return on investment. • Issues and challenges remain. • Future is bright, given the nature of how pharmacist care services have evolved in past 20 years.

  39. Questions?

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