<p><b>Background</b><br></p>
<p>More than 90% of individuals aged 65 years or
older in the United States (US) are taking at least one prescription
medication, and more than 40% are taking five or more prescription medications.
The potential for non-adherence and risk of medication therapy problems (MTPs)
increases with the use of multiple medications.
To enhance patient understanding of appropriate medication use, improve medication
adherence, and reduce MTPs, the Centers for Medicare & Medicaid Services
(CMS) launched Medication Therapy Management (MTM) services as part of Medicare
Prescription Drug (Part D) policy; however, “best practices” for achieving
positive MTM outcomes are not well understood.</p><p><br></p>
<p> </p>
<p><b>Objectives</b></p>
<p>This study had two objectives. The first objective was to identify
and explain reasons for concordance and discordance between a) consistently
high, moderate, and low performing pharmacies and b) pharmacies that improve or
worsen in performance overtime. The second objective was to generate hypotheses
for strategies that contribute to community pharmacies’ ability to achieve
high performance on widely accepted MTM quality measures. </p><p><br></p>
<p> </p>
<p><b>Methods</b></p>
<p>This comparative mixed-methods, case study design
incorporated two complementary conceptual models. First, an adaptation of the
Positive Deviance (PD) model explains reasons for deviations in MTM quality
measure performance among community pharmacies and informs study design.
Second, the Chronic Care Model (CCM) guided data collection and analysis. Data
consisted of pharmacy/staff demographics and staff interviews. When
appropriate, quantitative and qualitative data were analyzed within and across pharmacy
MTM performance (i.e., high, moderate, low) or change-in-performance (i.e.,
consistent, improved, worsened) categories using descriptive statistics and
cross-tabulation respectively. MTM performance component measures used to
evaluate and rank pharmacy MTM performance mirrored measures under Domain 4
(Drug Safety and Accuracy of Drug Pricing) of the 2017 CMS Medicare Part D Plan’
Star Rating measures. This study was approved by the Institutional Review Board for the Purdue University Human Research Protection Program. </p><p><br></p>
<p> </p>
<p><b>Results </b></p>
<p>Across the sample of eligible pharmacies (N = 56), MTM
performance composite scores varied by 21.3%. Of the five component scores, the
<i>Comprehensive Medication Review (CMR)</i>
component score had the highest percent variation (88.3%). Pharmacy staff at 13
pharmacies of the 18 pharmacies selected as case study sites participated in
interviews, yielding a 72.2% case pharmacy participation rate. Of the 13
pharmacies, five were categorized as high performers, four were moderate
performers, and four were low performers. Of the 39 pharmacy staff approached
across all pharmacies, 25 participated in interviews, yielding a 64.1%
participation rate. Interviewees included 11 pharmacists, 11 technicians and
three student interns. Eight strategies were hypothesized as positively (7) or
negatively (1) contributing to pharmacies’ MTM performance. Hypotheses
generated were organized by CCM elements and included: <i>Delivery System Design (DSD)</i> – Having a high degree of technician
involvement with MTM activities; Inability to meet cultural, linguistic, and
socioeconomic needs of patients (negative); Having sufficient capacity to
provide CMRs to patients in person compared to telephone alone; Pharmacy staff
placing high priority on addressing MTM activities<i>; Clinical Information Systems (CIS) </i>– Faxing adherence-related MTP
recommendations and calling providers on indication-related MTP
recommendations; Technicians’ use of CISs to collect/document information
for pharmacists; Using maximum number of available CISs to
identify eligible MTM patients; <i>Health
System Organizations (HSO) </i>– Strong pharmacist-provider relationships and
trust. No hypotheses were generated for the remaining three CCM elements.</p><p><br></p>
<p> </p>
<p><b>Conclusions
</b></p>
<p></p>A total of eight strategies were hypothesized as
contributing to community pharmacies’ ability to achieve high performance on
MTM quality measures. Notable strategies were related to three of the six
chronic care model elements. Future research should engage stakeholders to
assist with prioritizing hypotheses to be statistically tested in a larger
representative sample of pharmacies.
| Identifer | oai:union.ndltd.org:purdue.edu/oai:figshare.com:article/9108485 |
| Date | 12 August 2019 |
| Creators | Omolola A Adeoye (7042904) |
| Source Sets | Purdue University |
| Detected Language | English |
| Type | Text, Thesis |
| Rights | CC BY 4.0 |
| Relation | https://figshare.com/articles/Positive_Deviants_for_Medication_Therapy_Management_A_Mixed-Methods_Comparative_Case_Study_of_Community_Pharmacy_Practices/9108485 |
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