Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Cardiol. 2017 Sep 1;2(9):1019-1023. doi: 10.1001/jamacardio.2017.2172.
Many of the quality measures used to assess accountable care organization (ACO) performance in the Medicare Shared Savings Program (MSSP) focus on disease control and medication use among patients with cardiovascular disease and diabetes. To date, the association between participation in the MSSP by provider organizations and medication use or adherence among their patients with cardiovascular disease or diabetes has not been described.
To assess the association between exposure to the MSSP and changes in the use of and adherence to common antihypertensive, lipid-lowering, and hypoglycemic medications.
DESIGN, SETTING, AND PARTICIPANTS: Fee-for-service Medicare claims from January 1, 2009, to December 31, 2014, were used to conduct difference-in-differences comparisons of changes for ACO-attributed beneficiaries from before the start of ACO contracts to 2014 with concurrent changes for beneficiaries attributed to local non-ACO providers (control group). A random 20% sample of Medicare beneficiaries contributing 4 482 168 to 10 849 224 beneficiary-years for analysis from 2009 to 2014, depending on the drug class, was examined. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Data analysis was conducted from November 1, 2016, to April 5, 2017.
Patient attribution to an ACO after entry into the MSSP.
Any use (at least 1 prescription fill) and proportion of days covered (PDC), a standard claims-based measure of adherence, assessed for each of 6 drug classes: statins, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, β-blockers, thiazide diuretics, calcium channel blockers, and metformin.
Differences in patient characteristics between the MSSP and control group were generally small after geographic adjustment and changed minimally from the precontract period to 2014. There were no significant differential changes in medication use from the precontract period to 2014 for any cohort of MSSP ACOs in any drug class, except for a slight differential increase in the use of thiazides among beneficiaries with hypertension in the 2013 entry cohort (adjusted differential change, 0.5 percentage point; 95% CI, 0.1-0.8 percentage points; or 1.5% of the overall percentage using thiazides [33.4%], P = .01). Similarly, there were no significant differential changes in PDC among beneficiaries with at least 1 prescription fill, except for slight differential increases in the PDC for β-blockers in the 2012 entry cohort (adjusted differential change, 0.3 percentage point; 95% CI, 0.1-0.5 percentage points; or 0.4% of the mean PDC [82.3%], P = .003) and for metformin in the 2012 and 2013 cohorts (adjusted differential change, 0.5 percentage point; 95% CI, 0.1-0.9 percentage points; or 0.6% of the mean PDC [78.2%], P = .01 for both).
Exposure to the MSSP has not been associated with meaningful changes in medication use or adherence among patients with cardiovascular disease and diabetes.
重要性：许多用于评估医疗保险储蓄计划（MSSP）中责任医疗组织（ACO）绩效的质量措施都侧重于心血管疾病和糖尿病患者的疾病控制和药物使用。迄今为止，提供者组织参与 MSSP 与心血管疾病或糖尿病患者药物使用或依从性之间的关联尚未被描述。
目的：评估暴露于 MSSP 与常见降压药、降脂药和降糖药的使用和依从性变化之间的关联。
设计、环境和参与者：使用 2009 年 1 月 1 日至 2014 年 12 月 31 日的按服务收费的医疗保险索赔数据，通过从开始 ACO 合同前到 2014 年的 ACO 归因受益人的差异变化，与同期归因于当地非 ACO 提供者的受益人的变化（对照组）进行差异比较。分析了 2009 年至 2014 年取决于药物类别，从 Medicare 受益人群中随机抽取 20%的样本，每个受益人群有 4482168 至 10849224 个受益年限。分别估计了 2012 年、2013 年和 2014 年进入 MSSP 的 ACO 队列的差异变化。数据分析于 2016 年 11 月 1 日至 2017 年 4 月 5 日进行。
暴露：患者进入 MSSP 后的归属到 ACO。
主要结果和措施：评估了 6 种药物类别中每一种药物的任何使用（至少有 1 个处方填充）和比例覆盖率（PDC），这是一种基于标准索赔的药物依从性测量。
结果：经过地理调整后，MSSP 和对照组之间的患者特征差异通常较小，并且从合同前时期到 2014 年变化不大。除了 2013 年进入队列的高血压受益人群中噻嗪类药物的使用略有差异增加外（调整后的差异变化，0.5 个百分点；95%CI，0.1-0.8 个百分点；或噻嗪类药物总体使用百分比的 1.5%[33.4%]，P=0.01），任何 ACO 队列的任何药物类别中，从合同前时期到 2014 年，药物使用均没有显著的差异变化。同样，至少有 1 个处方的受益人群中，PDC 也没有显著的差异变化，除了 2012 年进入队列的β受体阻滞剂 PDC 略有差异增加（调整后的差异变化，0.3 个百分点；95%CI，0.1-0.5 个百分点；或 PDC 平均值的 0.4%[82.3%]，P=0.003）和 2012 年和 2013 年进入队列的二甲双胍 PDC 略有差异增加（调整后的差异变化，0.5 个百分点；95%CI，0.1-0.9 个百分点；或 PDC 平均值的 0.6%[78.2%]，P=0.01）。
结论和相关性：暴露于 MSSP 与心血管疾病和糖尿病患者的药物使用或依从性无明显变化相关。
