Clinical outcomes associated with receipt of integrated pharmacy services by hemodialysis patients: a quality improvement report.

BACKGROUND

Reducing medication-related problems and improving medication adherence in hemodialysis patients may improve clinical outcomes. In 2005, a large US dialysis organization created an integrated pharmacy program for its patients. We aimed to compare the outcomes of hemodialysis patients enrolled in this program and matched control patients.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS: Hemodialysis patients with concurrent Medicare and Medicaid eligibility who chose to receive program services and propensity score-matched controls; the propensity score was an estimated function of demographic characteristics, comorbid conditions, medication exposure, serum concentrations, and vascular access method.

QUALITY IMPROVEMENT PLAN

Program services included medication delivery, refill management, medication list reviews, telephonic medication therapy management, and prior authorization assistance.

OUTCOMES

Relative rates of death and hospitalization.

MEASUREMENTS

Survival estimates calculated with the Kaplan-Meier method; mortality hazards compared with Cox regression; hospitalization rates compared with Poisson regression.

RESULTS

In outcome models, there were 8,864 patients receiving integrated pharmacy services and 43,013 matched controls. In intention-to-treat and as-treated analyses, mortality HRs for patients receiving integrated pharmacy services versus matched controls were 0.92 (95% CI, 0.86-0.97) and 0.79 (95% CI, 0.74-0.84), respectively. Corresponding relative rates of hospital admissions were 0.98 (95% CI, 0.95-1.01) and 0.93 (95% CI, 0.90-0.96), respectively, and of hospital days, 0.94 (95% CI, 0.90-0.98) and 0.86 (95% CI, 0.82-0.90), respectively. Cumulative incidences of disenrollment from the pharmacy program were 23.4% at 12 months and 37.0% at 24 months.

LIMITATIONS

Patients were not randomly assigned to receive integrated pharmacy services; as-treated analyses may be biased because of informative censoring by disenrollment from the pharmacy program; data regarding use of integrated pharmacy services were lacking.

CONCLUSIONS

Receipt of integrated pharmacy services was associated with lower rates of death and hospitalization in hemodialysis patients with concurrent Medicare and Medicaid eligibility. Studies are needed to measure pharmacy program use and assess detailed clinical and economic outcomes.