Medpage Today Highlights Dr. Junling Wang’s Study: “COPD Medication Adherence: Effects of Comprehensive Medication Review“
Published Date: September 23, 2024 | By Leslie Burgess, Contributing Writer
Even as the number and type of medications to treat chronic obstructive pulmonary disease (COPD) expands, poor adherence with medication regimens remains a stubborn problem that undermines optimal patient outcomes and increases risk for disease exacerbations.1
As part of Medicare Part D’s medication therapy management (MTM) program, comprehensive medication reviews (CMR) are expected to improve adherence and optimize therapeutic effects. Yet uptake of these interventions in Medicare Part D plans remains low, partially due to cost and reimbursement concerns.2 A new study confirms that when instituted as recommended, CMR improves adherence and could help manage the costs of COPD management by reducing the need for emergency or other healthcare services related to poor COPD control.2
“Compared to non-CMR recipients, CMR recipients experienced a considerably higher increase in adherence to COPD medications from 2016 to 2017, and findings with data from more recent years are expected to be similar due to the lack of major MTM program change,” said Junling Wang, PhD, professor and vice chair for research in the Department of Clinical Pharmacy and Translational Research at the University of Tennessee College of Pharmacy in Memphis. “This finding adds critical empirical evidence to the literature on the benefits of MTM programs in improving medication adherence,” she added.
The analysis
To assess the impact of CMR, the study used Medicare data (2016-2017) combined with Area Health Resources files to create a snapshot of patient management as well as socioeconomic and demographic factors. All included patients were alive in 2017, had a diagnosis of COPD in 2016 and 2017, and were covered with Medicare Parts A, B, and D; those enrolled in Medicare Advantage plans were excluded. Per criteria from Medicare, patients eligible for MTM and CMR were those with ≥3 chronic illnesses, with ≥8 covered medications, and costs exceeding $3500 (2016) or $3900 (2017). In healthcare delivery, whether and how MTM and CMR are used varies among practices and insurance approaches.
“The University of Tennessee College of Pharmacy Department of Clinical Pharmacy hosts an MTM call center on each campus in collaboration with one of our clinical partners,” according to Chris Finch, PharmD, chair and professor at the College of Pharmacy Department of Clinical Pharmacy and Translational Science. “Since 2021, we have completed reviews for over 7000 patients. Nationally, pharmacists are at the center providing CMR and other MTM services to Medicare beneficiaries. They directly contact patients and follow up with them regarding their medication utilization issues,” said Dr. Finch.
Comparisons of adherence were between eligible patients who received CMR in 2017 (but not 2016) and those who did not receive it in either year (control group). Factors included in adjusted data were categorized as predisposing (race/ethnicity, gender, age, marital status, educational status) and enabling (income at community level, proportion uninsured, and census regional data). A third category of need factors included a risk adjustment summary based on diagnoses and demographic factors, with a higher score indicating worse health status and likely higher healthcare costs. The likelihood of receiving CMR was determined using a propensity score (using logistic regression) and matching between intervention and control groups was done using a “nearest-neighbor” algorithm. Sample size included a 3:1 matching between control and intervention groups, yielding 19,173 control patients and 6391 intervention patients for analysis.2
Adherence with long-acting inhaled bronchodilators was assessed using criteria from the Pharmacy Quality Alliance, using National Drug Codes for anticholinergics, beta-agonists, and combination medications, and number of days covered by ≥1 COPD medication divided by total number of days. Variables were analyzed using Chi-square (categorical) and t-tests (continual), and a Chi-square test for comparing adherence between intervention and control groups.
Differences in adherence
There were no significant differences in demographic or socioeconomic factors between intervention and control groups after propensity matching. In unadjusted data, there was no improvement in medication adherence in the control group between 2016 (68.88%) and 2017 (68.11%), whereas the intervention group saw a significant increase in adherence (60.08% to 69.38%; P <.0001). In adjusted analysis, receipt of CMR in 2017 was associated with a 59% increased likelihood of medication adherence (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.48-1.71) in the intervention versus control groups. The proportion of patients with high school or higher education also was associated with improved adherence (OR: 2.05, 95% CI: 1.06-3.95).2
According to Dr. Wang, “this study found that minority status—especially Black and Hispanic patients, being situated in the Southern region in the United States, having multiple chronic diseases and complex drug regimens, and residing in a county with a higher percentage of people attaining a minimum of a high school education were associated with a lower adherence rate to COPD medications. MTM providers should pay special attention to patients with these characteristics.”
Nonadherence with medications for COPD is associated with poorer outcomes, higher risk for exacerbations, and an estimated $30 billion in direct expenditures. Yet nonadherence remains prevalent, with adherence rates ranging from a low of 20% to a high of 60%. Reasons for nonadherence are as individual as the patients themselves, but some common themes include the complexity of regimens, the number of different drugs used, and—given the advanced age of the majority of patients with COPD—concerns about polypharmacy and adverse effects.2 Dr. Finch noted that “a key barrier to enhancing MTM enrollment is the need for more financial incentives for Part D sponsors because, since its inception, the costs associated with MTM services are built into sponsors’ annual Medicare bids, and Part D plans are not reimbursed separately from Medicare for the MTM services.”
The current study supports the broad benefit of medication therapy management and CMR in improving adherence among patients with COPD, making more extensive uptake of CMR an important goal in improving the lives of these patients. However, “CMR completion rates need to be improved; for example, the CMR completion rate among individuals potentially eligible for MTM services was only 12.6% in 2020. This remains a huge opportunity for pharmacists to play a pivotal role in chronic disease management,” added Dr. Finch.