Altavela Jeanette L, Jones Matt K, Ritter Merrilee
Greater Rochester Independent Practice Association, 60 Carlson Road, Rochester, NY 14610, USA.
J Manag Care Pharm. 2008 Nov-Dec;14(9):831-43. doi: 10.18553/jmcp.2008.14.9.831.
There is evidence that pharmacist interventions improve clinical outcomes. The few studies that address economic outcomes (a) often report estimated instead of actual medical costs, (b) report only medication costs, or (c) have been conducted in settings that are not typical of community-based primary care.
To (a) determine whether a clinical pharmacist's recommendations to physicians regarding optimizing medication therapy are related to medical costs in capitated patients in an internal medicine practice, and (b) compare what primary care physicians (PCPs) in a comparison group actually did proactively to optimize medication therapy versus what a clinical pharmacist would have recommended to them.
This was a prospective, controlled study comparing 2 internal medicine practices. Study enrollment was performed using a screening process carried out every 1-2 weeks on a rolling basis for 1 year from July 2001 through June 2002. Eligibility criteria for prospective enrollment were (a) 1 or more risk factors: at least 1 chronic disease or an event (e.g., emergency room visit, adverse drug reaction, medication nonadherence) or aged 50 years or older, (b) a scheduled visit to see a PCP within 2 weeks from the screening date or a diagnosis of diabetes without a PCP visit during the first 6 months of the study, (c) need for optimization of medication therapy as determined by a clinical pharmacist on the screening date, and (d) 12 months of continuous insurance eligibility before enrollment in the study. For inclusion in the final study analyses, patients were also required to have continuous insurance eligibility through 12 months from study enrollment. One clinical pharmacist made recommendations to optimize medication therapy in the intervention group. For the comparison group, the same pharmacist proposed recommendations that remained concealed from the physicians. The primary outcome measure was per patient per year (PPPY) medical cost, based on plan liability (gross allowable costs minus patient costs), excluding prescription drug cost. Additional outcome measures included numbers of outpatient visits, hospital admissions, emergency room (ER) visits per 1,000 patients, and hospital days; and percent of recommendations that were accepted by the PCPs. Changes in outcome measures from the pre-intervention to postintervention period were compared across study groups in a difference-indifference analysis, using the Student's t-test for normally distributed data and the Mann-Whitney U-test (nonparametric) for skewed data.
There were 127 and 216 adult patients in the intervention and comparison groups, respectively. The primary outcome, change in mean PPPY medical (excluding pharmacy) cost, did not differ significantly between the groups (P = 0.711). The between-group difference in the change in ER visits per 1,000 patients approached statistical significance (P = 0.054). Intervention group patients were more likely than comparison group patients to have the following issues addressed: medication nonadherence (85.7% vs. 40.0%, respectively; P = 0.032), untreated indication (72.6% vs. 11.5%, P < 0.001), suboptimal medication choice (60.0% vs. 5.9%, P < 0.001) and cost-ineffective drug therapies (72.1% vs. 6.5%, P < 0.001). Of the estimated number of actionable opportunities identified for the comparison group (but concealed from the physicians), 23.5% were adopted by comparison group physicians without any assistance from a clinical pharmacist.
Compared with patients of PCPs who received no input from a clinical pharmacist, patients of PCPs who received clinical pharmacist recommendations were more likely to have several medication-related issues addressed, including medication nonadherence, untreated indications, suboptimal medication choices, and cost-ineffective drug therapies. However, total medical (excluding pharmacy) costs for the intervention and comparison groups were not significantly different.
有证据表明药剂师的干预可改善临床结局。少数涉及经济结局的研究：（a）通常报告的是估计而非实际医疗成本；（b）仅报告药物成本；或（c）是在非典型社区初级保健环境中进行的。
（a）确定临床药剂师就优化药物治疗向内科医生提出的建议是否与按人头付费患者在内科实践中的医疗成本相关；（b）比较对照组中的初级保健医生（PCP）主动优化药物治疗的实际做法与临床药剂师会向他们提出的建议。
这是一项比较两个内科实践的前瞻性对照研究。从2001年7月至2002年6月，以滚动方式每1 - 2周进行一次筛选过程，为期1年，以纳入研究对象。前瞻性纳入的资格标准为：（a）1个或更多风险因素：至少1种慢性病或1次事件（如急诊就诊、药物不良反应、用药依从性差）或年龄50岁及以上；（b）筛选日期后2周内计划就诊PCP，或在研究的前6个月内诊断为糖尿病但未就诊PCP；（c）临床药剂师在筛选日期确定需要优化药物治疗；（d）入组研究前连续12个月有保险资格。为纳入最终研究分析，患者还需从研究入组起连续12个月有保险资格。一名临床药剂师在干预组中提出优化药物治疗的建议。对于对照组，同一名药剂师提出建议，但对医生隐瞒。主要结局指标是基于计划责任（总允许成本减去患者成本）的每位患者每年（PPPY）医疗成本，不包括处方药成本。其他结局指标包括门诊就诊次数、住院次数、每1000名患者的急诊（ER）就诊次数和住院天数；以及PCP接受建议的百分比。在差异分析中，使用Student's t检验分析正态分布数据，使用Mann - Whitney U检验（非参数）分析偏态数据，比较研究组干预前至干预后结局指标的变化。
干预组和对照组分别有127名和216名成年患者。主要结局指标，即PPPY医疗（不包括药房）成本的平均变化，两组间无显著差异（P = 0.711）。每1000名患者急诊就诊次数变化的组间差异接近统计学意义（P = 0.054）。干预组患者比对照组患者更有可能解决以下问题：用药依从性差（分别为85.7%对40.0%；P = 0.032）、未治疗的适应证（72.6%对11.5%，P < 0.001）、药物选择欠佳（60.0%对5.9%，P < 0.001）和成本效益不佳的药物治疗（72.1%对6.5%，P < 0.001）。在为对照组确定的（但对医生隐瞒的）可采取行动机会的估计数量中，23.5%被对照组医生在没有临床药剂师任何协助的情况下采用。
与未接受临床药剂师建议的PCP的患者相比，接受临床药剂师建议的PCP的患者更有可能解决几个与药物相关的问题，包括用药依从性差、未治疗的适应证、药物选择欠佳和成本效益不佳的药物治疗。然而，干预组和对照组的总医疗（不包括药房）成本无显著差异。
