Stephanie A. Roberts, PharmD, BCPS University of California, Davis Health System (UCDHS)

1. Effect of Pharmacist-Led Comprehensive Medication Management on Chronic Disease State Goal Attainment Stephanie A. Roberts, PharmD, BCPS University of California, Davis Health System (UCDHS) August 13, 2018

2. Conflicts of Interest • No conflicts of interest to disclose

3. Objectives • Identify disease state goal attainment rates that improved at UCDHS outpatient clinics after embedding pharmacists on the primary care team • List future steps being taken to expand the pharmacist’s role in the primary care setting at UCDHS

4. Need for Pharmacists in Primary Care • Medications are involved in 80% of all treatments • Nearly 70% of Americans receive 1+ prescription drugs • Up to 50% took a prescription drug in the last 30 days • Medication management is key to positive outcomes • One-third of adverse drug events lead to hospitalization • Only half of all patients are adherent to prescribed therapies for chronic conditions • Over 50% of U.S. physicians reported their patients have difficulty with medication costs PCPCC Medication Management Task Force. Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Second Edition. June 2012. Zhong W, et al. Age and Sex Patterns of Drug Prescribing in a Defined American Population. Mayo Clin Proc. 2013;88(7):697-707. CDC. Therapeutic Drug Use. http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm. March 23, 2015. Budnitz DS, et al. National Surveillance of Emrgency Department Visits for Outpatient Adverse Drug Events. JAMA. 2006;296:1858-1866. World Health Organization. Adherence to Long-Term Therapies: Evidence for action. 2003.

5. Pharmacist’s role on the Care Team • Recognized as healthcare providers and essential members of the primary care team • Support patient-centered medication use by providing: Giberson S, et al. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. December 2011. Smith M, et al. Why Pharmacists Belong In The Medical Home. Health Affairs. 2010; 29(5):906-913.

6. Integration of Pharmacy Services at UCDHS • Initially a two-year pilot project – started August 2014 • Consisted of two pharmacists and one pharmacy technician • Located at seven UCDHS patient care network (PCN) clinics • Implementation of clinical pharmacy services • Face-to-face in-clinic pharmacy visits • Utilization of collaborative-practice agreements • Prior authorization services • NCQA recognition as a Patient-Centered Medical Home

7. Goals of the Pharmacy PCN Pilot • Meet defined chronic disease state metrics • Initiate or modify medications based on patient-specific goals • Order labs for disease state and medication monitoring • Identify and aid in resolving medication use barriers • Provide comprehensive medication reconciliation and review • Assist with medication access issues and cost concerns • Offer medication and disease state self-management tools • Deliver extensive medication education and counseling

8. Pharmacist Daily Activities Initial 40 minute clinic visits

9. Evaluation of Outcomes from the Pilot • Single – center matched retrospective chart review • Patient population • Type II diabetics seen between 10/1/14 and 10/31/15 • Documented engagement in care • Seen for more than one pharmacy F2F clinic visit OR one pharmacy F2F clinic visit and >1 telephone encounters • Two primary care provider (PCP) office visits • Stratified into an intervention and usual care group Prudencio J, et al. J Manag Care Spec Pharm. 2018;24(5):423-29.

11. Defined Disease State Metrics • Bundled response score (BRS) • Attainment of defined glycemic, blood pressure (BP), and lipid parameter goals • Ranked zero to three - higher number representing better control • Chronic disease state goals • Hemoglobin A1c goal attainment • HgbA1c less than or equal to 8% • Lab drawn at least 90-days following the last pharmacy or PCP clinic encounter • BP goal attainment • BP less than or equal to 140/90 mmHg • Recorded at the last clinic encounter or the first PCN clinic visit following the last pharmacy clinic encounter • Lipid parameter goal attainment • Utilization of a moderate to high intensity statin medication • Recorded at the last pharmacy or PCP clinic encounter American Diabetes Association. Diabetes Care 2015;38(Suppl. 1):S5–S7 James PA, Oparil S, Carter BL, et al. JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF. Circulation. 2013.

17. Summary • Pharmacist intervention within the UCDHS PCN resulted in improved therapeutic outcomes: • Hemoglobin A1c:  1.4% • Blood pressure (SBP / DBP):  7.4 / 2.4 mmHg • Potential to play a key role in delivery system reform • Enhanced ability to achieve pay-for-performance goals • Lower health care costs and utilization • Reduced risk of disease-associated complications Bodenheimer TS and Smith MD. Health Affairs. 2013; 32(11):1881-1886. Wagner EH, et al. JAMA. 2001;285:182-189. Law MR, et al. BMJ. 2009;338:b1665. Stratton IM, Alder AL, Neil HAW, et al. BMJ. 2000;321(7258):405-12.

18. Medication Optimization = Better Outcomes • Improved A1c and BP goal attainment rates WITHOUT increasing the average number of medications prescribed • Utilization of motivational interviewing techniques • Frequent pharmacist inventions includes: • Medication dosage and drug adjustments • Reducing medication drug costs • Implementation of self-management tools • Providing educational resources and counseling

19. Next Steps • Place pharmacists on the care team at all PCN clinic sites • Expand the pharmacist’s clinical responsibilities • Assistance with pain management and anticoagulation • EMR pharmacy econsults • Alignment of services with institution wide metrics • Define VALUE

20. References PCPCC Medication Management Task Force. Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Second Edition. June 2012. Zhong W, et al. Age and Sex Patterns of Drug Prescribing in a Defined American Population. Mayo Clin Proc. 2013;88(7):697-707. CDC. Therapeutic Drug Use. http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm. March 23, 2015. Budnitz DS, et al. National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events. JAMA. 2006;296:1858-1866. World Health Organization. Adherence to Long-Term Therapies: Evidence for action. 2003. Giberson S, et al. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. December 2011. Smith M, et al. Why Pharmacists Belong In The Medical Home. Health Affairs. 2010; 29(5):906-913. Prudencio J, Cutler T, Roberts S, et al. The Effect of Clinical Pharmacist-Led Comprehensive Medication Management on Chronic Disease State Goal Attainment in a Patient-Centered Medical Home. J Manag Care Spec Pharm. 2018;24(5):423-29. American Diabetes Association. Strategies for improving care. Sec. 1. In Standards of Medical Care in Diabetesd2015. Diabetes Care 2015;38(Suppl. 1):S5–S7 James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013. Bodenheimer TS and Smith MD. Primary Care: Proposed Solutions to the Physician Shortage without Training more Physicians. Health Affairs. 2013; 32(11):1881-1886. Wagner EH, et al. Effect of Improved Glycemic Control on Health Care Costs and Utilization. JAMA. 2001;285:182-189. Law MR, et al. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. Stratton IM, Alder AL, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405-12.