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Telephone-Based Cardiovascular Medication Therapy Management in Medicare Part D Enrollees With Diabetes

A telephonic pharmacist-delivered medication therapy management intervention is an effective method for increasing the utilization of guideline-recommended cardiovascular therapies in high-risk Medicare patients with diabetes.

Published Online: May 10,2017
Eleanor O. Caplan, PharmD, PhD; Mignonne C. Guy, PhD; Jean Chang, BS; and Kevin Boesen, PharmD
Objectives: The purpose of this study was to evaluate the impact of pharmacist-delivered medication therapy management (MTM) services via telephone (enhanced MTM intervention) versus the impact of an informative detailed medication letter sent via mail (minimal MTM intervention) on patients’ acceptance of guideline-recommended pharmacotherapies, specifically angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) and statins. 
Study Design: A retrospective database analysis was completed using pharmacy claims and enrollment data from 1 national pharmaceutical benefits manager. 
Methods: Medicare Part D beneficiaries with diabetes, managed by 1 pharmacist-based medication management center, received either: 1) a pharmacist’s recommendation, delivered via telephone, to add an ACE inhibitor or ARB and/or a statin to existing therapy, or 2) an informative letter detailing current therapies. The primary outcome measure was acceptance of guideline-recommended therapy determined by the presence of at least 1 prescription claim for the target drug in the postintervention period. Propensity score matching and conditional logistic regression methodologies were used to assess the comparative effectiveness of the interventions. 
Results: Patients who received the telephone intervention were 6.33 times more likely to be taking both medications during the postintervention period compared with those who received the letter intervention (P <.001). A greater proportion of patients who received the telephone intervention were taking both drugs during the postintervention period, with the greatest difference in those initially receiving a statin to which ACE inhibitor/ARB therapy was added (41.18% vs 7.23%). 
Conclusions: Telephone-based MTM services provided to Medicare Part D beneficiaries with diabetes positively impacted acceptance of guideline-recommended ACE inhibitor/ARB and/or statin therapies relative to the letter intervention.
Am J Pharm Benefits. 2017;9(2):-0

 According to 2014 national estimates provided by the CDC, 29.1 million people in the United States live with diabetes, with 8.1 million of these individuals being undiagnosed.1 The prevalence of this disease in those 65 years or older is 25.9%, with this age group accounting for more than a third of all individuals with diabetes in the United States.1
One study projected that by 2050, incident cases of diabetes are expected to almost double and the prevalence will increase to between 21% and 33% of the entire population based on 2010 estimates.2 The economic burden of diabetes has been estimated at $174 billion, including direct medical costs, reduced productivity, and costs to treat diabetes-related chronic conditions.3 Chronic conditions that have the largest impact on resource consumption in patients with diabetes include cardiovascular disease (CVD), neurological symptoms, and renal complications.3
Behind healthcare expenditures for inpatient hospital stays for general medical conditions, CVD-related inpatient resource consumption is the second largest category of associated costs.3 Moreover, CVD is the leading cause of morbidity and mortality in diabetics, with death from coronary heart disease (CHD) 2 to 3 times higher in patients with diabetes than those without.4,5 
Multiple associations have each developed guidelines for the management of CVD risk factors.5-8 The 2010 American Diabetes Association (ADA) guidelines detail current standards of medical care and CVD management in diabetics.5 Recommendations for the prevention and management of CVD include blood pressure control, lipid management, use of antiplatelet agents, smoking cessation, and screening for/treatment of CHD.4
Hypertension and dyslipidemias remain the most prevalent comorbidities in patients with diabetes. In addition to diet and lifestyle modifications, first-line pharmacotherapy for diabetics with a diagnosis of hypertension include either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB).
Studies have demonstrated risk reductions in morbidity and mortality associated with cardiac events resultant from primary or secondary prevention interventions.9-12 Aggressive lipid management with hydroxymethylglutaryl coenzyme-A reductase inhibitors (statins), along with diet and lifestyle modifications, is also a first-line recommendation of the ADA.
Patients 40 years or older with diabetes and either overt CVD or without overt CVD (but who have 1 other risk factor for CVD regardless of baseline cholesterol levels) are indicated for pharmacotherapy.4 The efficacy of statins in primary and secondary prevention of cardiovascular events in patients with diabetes has also been well established.10,13-18