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Release: Jan. 21, 2003

UI researchers evaluate program to improve medication safety

A team-approach used by community pharmacists and physicians taking part in a state program designed to improve medication safety for Medicaid-eligible patients can be effective, according to University of Iowa researchers who evaluated the program.

Researchers from the UI Colleges of Public Health and Pharmacy evaluated the Iowa Medicaid Pharmaceutical Case Management (PCM) program, established with an appropriation by the Iowa Legislature in 2000 and part of the Iowa Department of Human Services.

The program is based on the concept of pharmaceutical care, where pharmacists take an active, even proactive, role in the drug regimens of patients – communicating with physicians and identifying potential problems with drug interaction and drug duplication. By working together, doctors and pharmacists find the best combination of drugs and doses for Medicaid patients, especially those with multiple diseases.

"This model of care has proven to be very effective in hospital and clinic settings, where pharmacists and physicians are under the same roof and have the same access to a patient's medical record," said Elizabeth Chrischilles, Ph.D., professor of epidemiology in the UI College of Public Health. "The Iowa Medicaid PCM program, however, looked to deliver this care in a community setting, without the benefit of shared locations or shared access to patient records."

The program is available to Medicaid-eligible Iowans who are taking at least four medications and have at least one of 12 specific diseases. Participating pharmacists (those who are certified in pharmaceutical care or have a doctor of pharmacy degree) perform an initial assessment for their eligible patients' drug regimens. The pharmacist identifies any potential or existing problems and makes a recommendation to the patient's physician, who assesses and then accepts, rejects or modifies a recommendation. The pharmacist makes follow-up assessments, communicating to the physician each time. Once problems are resolved, preventive follow-up assessments occur every six months.

Both pharmacists and physicians can be reimbursed through Medicaid for the care they provide.

UI researchers collected data on the program, analyzing pharmacist and patient questionnaires and evaluating Medicaid claims for reimbursement. They also studied the pharmacists' patient records to measure the medication appropriateness and change over time.

The researchers' findings included:

• Medicaid patients eligible for the PCM program are at a very high risk for problems with medications. As many as 30 percent of the patients self-reported an adverse drug reaction in the previous year, which was three times the rate found in a separate group of elderly Iowans not on Medicaid. Approximately 35 percent of the PCM-eligible patients had drug-drug interactions. Moreover, among those patients age 60 and older, approximately 75 percent had a drug-drug interaction.

• A total of 117 pharmacies around the state participated in the program. Of more than 3,000 patients eligible in the first year of the program, pharmacists met with 943 and sent recommendations to doctors for 500 of these patients. The most common recommendation made by pharmacists was to start a new medication (52 percent of patients). Pharmacists recommended a change in medication 36 percent of the time, indicating a better therapy might be available. Pharmacists also recommended discontinuation of medications 33 percent of the time.

• The PCM program improved medication safety and did not measurably affect Medicaid expenditures. Medicaid paid a total of $94,170 for PCM services through May 31, 2002. Even after including the amount paid for PCM services, there was no net increase in health care utilization or charges among patients who received PCM services compared to those eligible who did not receive the services.

The UI researchers reported that the PCM program could be even more effective with additional training to pharmacists and physicians and increased awareness about the program.

"Pharmacists were given some training on this program before it started, while physicians were not," Chrischilles said. "So some physicians did not know that they could be reimbursed for these types of services. The onus was really on the pharmacists to inform their patients' physicians about the program."

Unlike doctors' offices, pharmacies lack support staff to gather medical records, schedule patients and keep records. Thus, pharmacists had to do this work themselves in addition to their other responsibilities, which meant that the level of participation among pharmacists varied, Chrischilles noted.

"Our study showed that this program did appear to improve medication safety, so as the program develops it has the potential to benefit a greater number of patients, " she said. "Fostering the pharmacist-physician team approach through additional training and dialogue was part of our recommendations for the program."

The PCM program was implemented by the legislature as a state plan amendment, meaning that the program is continuing and is available to all eligible Medicaid recipients. The Iowa Pharmacy Association and the federal Centers for Medicare/Medicaid Services funded the UI evaluation of the program.