Parikh Megha A, Ramachandran Sujith, Nsiah Irene, Campbell Patrick J, Castora-Binkley Melissa, Karmakar Taruja, Black Heather, Bentley John P
Pharmacy Quality Alliance, Alexandria, VA.
University of Mississippi School of Pharmacy, University.
J Manag Care Spec Pharm. 2025 Jan;31(1):25-32. doi: 10.18553/jmcp.2025.31.1.25.
The Centers for Medicare and Medicaid Services (CMS) Star Ratings program incentivizes health plans in Medicare to improve performance on a variety of quality measures such as adherence to renin-angiotensin system antagonists (RASAs). Adherence to RASA medications, defined as having a proportion of days covered (PDC) of at least 80%, has been improving for several years, suggesting that further investigation is needed to assess the appropriateness of the current 80% PDC threshold for medication adherence as an indicator of quality. The 80% PDC threshold has been found to be associated with improved health care resource utilization outcomes; however, little evidence exists to show that this threshold is optimal.
To evaluate the association between adherence to RASA medications and health care resource utilization outcomes within a Medicare Advantage population and to identify the optimal PDC threshold that maximizes economic and utilization benefits.
This retrospective cohort study used de-identified administrative claims data from the 2015 to 2018 in Optum's de-identified Clinformatics Data Mart Database. Inclusion in the study was based on measure specifications for the RASA adherence measure used in the Medicare Part D Star Ratings program. Adherence was assessed over a 1-year period, and health care utilization and medical costs were assessed in the subsequent year. Multivariable logistic regression models were used to assess the relationship between adherence and economic outcomes after accounting for hypothesized confounders.
A total of 1,006,901 individuals were included in the study with an average PDC of 87.5% (SD = 17.8%). During the follow-up period, 12.1% of individuals experienced a hospitalization, 14.81% used an emergency department (ED), and 32.3% visited a non-ED outpatient facility. Each percentage point increase in PDC was significantly associated with decreased odds of hospitalization (odds ratio [OR] = 0.997; 95% CI = 0.997-0.997) and ED visit (OR = 0.997; 95% CI = 0.996-0.997), being in the top decile of payer medical costs (OR = 0.998; 95% CI = 0.997-0.998), and increased odds of outpatient visits (adjusted OR = 1.001; 95% CI = 1.001-1.002). Receiver operator characteristic curve analyses found the optimal PDC thresholds to be 91.5%, 90.7%, 90.7%, and 90.4% for hospitalization (area under the curve [AUC] = 0.527), ED visit (AUC = 0.534), outpatient visit (AUC = 0.501), and medical costs (AUC = 0.532), respectively.
This study demonstrated the importance of medication adherence for preventing undesirable outcomes, such as future hospitalizations, ED visits, and high medical costs, among individuals with hypertension enrolled in Medicare Advantage. The optimal threshold for PDC related to health care resource utilization outcomes was found to be greater than that used in the measure in CMS Star Ratings. Future research should examine the impact of changes in adherence thresholds for economic and clinical outcomes.
医疗保险和医疗补助服务中心（CMS）的星级评定计划激励医疗保险中的健康计划在多种质量指标上提高绩效，如肾素 - 血管紧张素系统拮抗剂（RASAs）的依从性。RASA药物的依从性定义为覆盖天数比例（PDC）至少为80%，多年来一直在提高，这表明需要进一步调查，以评估当前80%的PDC阈值作为药物依从性质量指标的适宜性。已发现80%的PDC阈值与改善医疗资源利用结果相关；然而，几乎没有证据表明该阈值是最佳的。
评估医疗保险优势人群中RASA药物依从性与医疗资源利用结果之间的关联，并确定能使经济和利用效益最大化的最佳PDC阈值。
这项回顾性队列研究使用了Optum的去识别化临床信息数据集市数据库中2015年至2018年的去识别化管理索赔数据。纳入研究基于医疗保险D部分星级评定计划中使用的RASA依从性指标的测量规范。在1年期间评估依从性，并在随后一年评估医疗资源利用和医疗费用。在考虑假设的混杂因素后，使用多变量逻辑回归模型评估依从性与经济结果之间的关系。
共有1,006,901人纳入研究，平均PDC为87.5%（标准差 = 17.8%）。在随访期间，12.1%的人住院，14.81%的人使用过急诊科（ED），32.3%的人就诊于非急诊科门诊机构。PDC每增加一个百分点，与住院几率降低（优势比[OR] = 0.997；95%置信区间 = 0.997 - 0.997）、ED就诊几率降低（OR = 0.997；95%置信区间 = 0.996 - 0.997）、处于支付方医疗费用最高十分位的几率降低（OR = 0.998；95%置信区间 = 0.997 - 0.998）以及门诊就诊几率增加（调整后OR = 1.001；95%置信区间 = 1.001 - 1.
