• An economic and outcome evaluation of the Pharmaceutical Care Services Program for Maryland Medicaid recipients

      Lai, Li-An Leanne; Speedie, Stuart M. (1996)
      The goal of this research was to determine if the Pharmaceutical Care Services Program (PCSP) significantly changes the utilization and cost of medical services for Medicaid recipients. The University of Maryland Center on Drug and Public Policy (CDPP) has contracted with the Maryland Department of Health and Mental Hygiene (DHMH) to provide pharmaceutical care services for Maryland Medicaid recipients. The main goal of PCSP is to improve the appropriateness and cost-effectiveness of physician prescribing decisions and patient drug use. The program accomplishes this by placing clinical pharmacists in hospital clinics to review drug therapy and provide advice to physicians and counseling to patients. A quasi-experimental pretest and post-test design with three control groups was performed in this study. The subjects who received PCSP and met the study criteria were the study group. The subjects who were Medicaid enrollees and relatively similar to the study subjects in terms of age, sex, hospital, and ACG (ambulatory care group) classification were randomly selected into the control groups by using a multiple computerized matching process. Differences in utilization and cost of medical services between study and control groups were tested for statistical significance. Cost-benefit analyses were then performed from budgetary and societal perspectives by applying a net present value method. The mortality and morbidity productivity loss estimations were specifically addressed as the indirect benefits in this study. Lastly, a sensitivity analysis was performed to test the assumptions (discount rate and wage rate) underlying the analysis. In this study, the utilization and costs comparisons between the PCSP patients and control patients revealed that: (1) PCSP "capped" the total cost of services by holding them constant while the control groups' costs rose sufficiently to create a significant difference between the PCSP and control groups; (2) specialty care physician visits remained stable for PCSP while increasing in the control groups; (3) primary care physician visits remained stable for PCSP recipients while they declined in the control groups; (4) less prescription medication was used in PCSP group than in the control group; (5) while the total cost of prescriptions increased for both groups, the cost of PCSP prescriptions was less than the control group cost; (6) PCSP showed no significant impact on the use of the emergency room and hospitalizations. The cost-benefit analysis illustrates that PCSP saved the Medicaid program $204.32 per patient for the first year intervention and $2,043.20 for the future 10 years from a budgetary perspective. From a societal perspective, PCSP saved society $4,116.01 per patient for the future 10 years period. Theoretically, if PCSP were expanded to serve all Medicaid, adult, non-institutionalized patients receiving drug therapy, the state of Maryland should be able to save as much as $27 million in the next fiscal year from a budgetary perspective. The society should be able to save as much as $259 million in the next fiscal year from both direct and indirect savings.
    • An epidemiologic evaluation of hospitalizations of elderly Medicare beneficiaries due to adverse reactions to anticoagulant therapy using claims data

      Fitterman, Leslye K.; Speedie, Stuart M. (1995)
      The objective was to examine a representative population of elderly persons in the United States to (1) provide an estimate of the number of persons taking oral anticoagulants, (2) estimate the rate of anticoagulant adverse drug reaction (ADR) hospitalizations, (3) describe patient demographic and clinical characteristics, and (4) examine patient and provider characteristics in relation to an anticoagulant ADR. The retrospective case-control study used the Health Care Financing Administration's Medicare program claims and administrative data. The case-control subjects were "presumed" to be being monitored for anticoagulant treatment. The selection criteria excluded those with less than three prothrombin time tests PTs and no claim indicating one of the following diagnoses; pulmonary embolism, atrial fibrillation with embolism or, deep vein thrombosis. The number of subjects in the study was 1,135 cases and 7,133 controls. The estimated number of persons "presumed" to be monitored for anticoagulant therapy was 2 million. Incidence rates of ADR hospitalizations and anticoagulant ADR hospitalization per 1,000 hospitalizations were found to be 22.99 and 1.17. This study found that although anticoagulant ADRs are rare, the finding may be an underestimate. The only patient demographic characteristics found to be associated with ADRs was gender. Females were at risk for an ADR. The relationship between structure, process, and outcomes, (an effectiveness model) identified factors that increase the risk for an anticoagulant ADR hospitalization. Persons who had PTs done in physician office laboratories were at slightly greater risk for an adverse outcome than persons who had PTs done in commercial laboratories. Persons in the case-control group had a high mean number of interactions with the health care system, between 1 and 2 a week suggesting that persons on anticoagulant therapy account for a relatively high amount of utilization. Carcinoma, hypertension, renal insufficiency, congestive heart failure and hepatic disorders were confirmed as risk factors for an adverse outcome. But, because of the under-reporting of ADRs, it is likely that there is misclassification of cases as controls. Thus, there is bias towards the null for all the risk factors, and if anything, those factors associated with ADRs are underestimates.