PCMH Tied to Better Adherence for Chronic Disease Medication

Marcia Frellick

November 14, 2016

Patients with chronic conditions who received care in patient-centered medical homes (PCMHs) had 2% to 3% better medication adherence than patients in other practices, new nationwide data show.

Julie C. Lauffenburger, PharmD, PhD, from the Department of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital in Boston, Massachusetts, and colleagues, studied Aetna claims between 2011 and 2013 and calculated adherence 12 months after patients started common medications for chronic diseases, including diabetes, hypertension, and hyperlipidemia.

They compared adherence between patients of PCMHs recognized by the National Committee for Quality Assurance and those in control practices in the same primary care service areas.

Of the 313,765 patients who met the study criteria, 18,611 (5.9%) received care in PCMHs. Adherence rates averaged 64% among PCMH patients and 59% among control patients.

Moreover, among 4660 matched control and medical home practices, adherence was significantly higher in PCMHs (2.2% [95% confidence interval (CI), 1.5% - 2.9%]).

Better adherence rates did not differ significantly by disease for those in PCMHs. They were as follows: diabetes, 3.0% (CI, 1.5% - 4.6%); hypertension, 3.2% (CI, 2.2% - 4.2%); and hyperlipidemia, 1.5% (CI, 0.6% - 2.5%).

The authors say the findings, published online November 14 in the Annals of Internal Medicine, have policymaking implications and that incentives rewarding medical home use "may substantially improve quality of care and patient engagement, ultimately decreasing costs."

A previous study in 2015 comparing PCMHs with controls among North Carolina Medicaid beneficiaries found even higher rates of adherence for PCMH patients: about 3% to 6% higher than in control patients, depending on the disease state.

Dr Lauffenburger and colleagues said numbers in the current study may have been lower than the North Carolina study's because of geographic differences, variations in medical home features, or analytic approach.

Overall, positive data linked with PCMHs has tended to come from larger, integrated health systems. Smaller practices have seen less positive results.

In an accompanying editorial, Michele Heisler, MD, MPA, from the University of Michigan and Veterans Affairs Ann Arbor Healthcare System, praised the current study, noting the importance of improving adherence rates, a key factor linked with better outcomes and lower healthcare costs.

30% Never Fill New Prescriptions

She points out that adults with chronic conditions "never fill up to 30% of new prescriptions and persist in taking about 50% of chronic disease medications," which is a major factor in avoidable hospitalizations, disease complications, and death.

The authors' methods were more rigorous than those of previous studies, she writes.

But the study is limited in the conclusions it can draw about whether the 2% improvement in adherence rates is clinically significant, she says, because the optimal threshold for adherence and the percentage increase needed to show clinical improvement are not well established for many medications.

The next step will be to see what features of the PCMH are most critical for improving adherence and then associated clinical outcomes.

But success must be measured beyond adherence, she writes: "[T]he true next frontier is to measure improvements in domains that patients identify as being most important to them. Future assessments of quality of care in patient-centered medical homes must also evaluate the extent to which patients' own health goals are identified and met."

She says successful PCMHs will be those that perform well in four areas: developing trusting, collaborative provider-patient relationships; systematically tracking adherence to medications from all prescribers and identifying barriers; identifying patients who need more support to take medications; and providing support between face-to-face visits.

This study was supported by an unrestricted grant from CVS Health to Brigham and Women's Hospital. Dr Lauffenburger reports a grant from CVS Health during the conduct of the study. Coauthors report personal fees from Johnson & Johnson outside the submitted work; employment and stock ownership with CVS Health at the time of this work; a consultancy for the Center for Medicare and Medicaid Innovation; employment with Brigham and Women's Hospital and Ariadne Labs; grants from the Bill & Melinda Gates Foundation, World Bank Group, Novartis and Pfizer outside the submitted work; employment with Aetna outside the submitted work; grants from CVS Caremark during the conduct of the study and from Sanofi, AstraZeneca, Medisafe, the National Heart, Lung, and Blood Institute, Merck and Pharmaceutical Research and Manufacturers of America outside the submitted work. Dr Heisler has disclosed no relevant financial relationships.

Ann Intern Med. Published online November 15, 2016. Abstract, Editorial

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