Cost‐Related Medication Adherence and Patients’ Experience with the Chronic Care Model
Veterans Affairs Health Services Research
& Development (VERDICT)
University of Texas Health Science Center
at San Antonio
 John E. Zeber, PhD
 Luci Leykum, MD
 Michael
Mi h l L.
L Parchman,
P
h
MD
 Raquel Romero, MD
 Krista Bowers, MD
The communication and
coordination
di ti off scattered
tt d ffragments
t
of knowledge is perhaps the basic
problem of any society
- Thomas Sowell
It seems rather incongruous that in a
society of super-sophisticated
communication we often suffer
communication,
from a shortage
g of listeners
- Erma Bombeck
“And that one’s for the relief of anxiety
caused by the high cost of medication”
Introduction
Medication adherence is a significant concern for
patients
ti t with
ith chronic
h i h
health
lth conditions
diti
((~40%)
40%)
Scenario frequently
q
y exacerbated by
y financial
considerations (15-20% restrict Rx due to cost) 1-2
Age, ethnicity,
Age
ethnicity multiple comorbidities,
comorbidities and severity of
illness compounds the problem
Fortunately, provider and organizational factors can
mitigate
g
medication cost burdens
1 - Piette et al., AJPH 2004; 2 – Maciejewski et al., AJMC 2010
Implementation of CCM can yield more activated patients
(CVD behaviors
more engaged in their own TX (CVD,
behaviors, A1c –
bunch of Parchman et al. stuff)
Such patients have better adherence, therefore leading
to significantly improved clinical outcomes
illness insight, therapeutic alliance and other
psychosocial barriers 3-5
trust in physicians 6
self-activation and communication 7
alliance and cost burden 8
3 – Copeland et al., J Nerv Ment Dis 2008; 4 – Zeber et al., J Aff Dis 2008; 5 – Zeber et al., Adm Policy MH (in press); 6 –
Piette at al., Arch Int Med 2005; 7 – Parchman et al., Ann Fam Med (in press); 8 – Zeber et al., 2009 (conference abstract)
p = .013
Better CCM Delivery
y = Lower A1c
8.2
8.1
8
7.8
7.8
Mean A1c 7.6
7.4
7.4
72
7.2
7
Low
Medium
Chronic Care Model Score
p <.01
High
Objectives
Research Purpose:
1) This study examines the association between
patients’ experience of the CCM and reported
patients
cost-related medication adherence burden
2) Share some quantitative findings concerning the
CCM PCMH overlap
Methods & Studyy Design
g
ABCs project: main objective = help facilitate the
implementation of the Chronic Care Model / PCMH in small
community clinics and risk factors for diabetes complications
A = A1c
B = Blood pressure
C = Cholesterol
Primary goal is determining how practice facilitation efforts
can influence better implementation of the CCM
ABCs: a conceptual model
Facilitation efforts &
Toolkit of Strategies
“Toolkit”
Leadership
Communication
Learning
Implementation of
CCM / PCMH
Improved A1c
control and other
clinical outcomes
↑ Activation /
Self-engagement
↑ Medication
Adherence
Population Studied: Patients with chronic medical
illness at 40 small, primary care offices in South Texas
Randomized trial: initial intervention group (20) and
delayed control group (20)
Complex
C
l study:
t d observations,
b
ti
ffacilitation
ilit ti sessions,
i
provider and staff interviews, patient surveys, chart
reviews, dissemination
study we utilized patient survey data only:
For this study,
60 randomly selected patients per clinic
Measures & Analysis
Cost-related adherence burden (CRAB) was measured
with a 5
5-item
item scale (Piette et al.)
higher scores reflect more medication restrictions
Patient Assessment of Chronic Illness Care (PACIC) 9
20 item instrument assessing perceptions of primary care
20-item
treatment; higher values = care more consistent with CCM
Random effects models controlled for nesting of patients,
plus demographics
p
g p
9 – Glasgow et al., Med Care 2005
Results
To date, 1368 patients completed both baseline surveys
P ti t characteristics:
Patient
h
t i ti
mean age = 50.1 years
65% women, approximately 50% Hispanic
overallll self-reported
good
lf
t d health
h lth status:
t t
d = 75%
poor medication adherence = 45%, with nearly 30% claiming
some cost-related problems.
CRAB scale mean was 1.50
1 50 (sd 0.82)
0 82), with an overall
PACIC mean of 3.02 (sd 1.25)
Table 1: Study Population Characteristics (n = 1368)
Age mean (sd)
Age,
Women
Race / Ethnicity
% White
% Hispanic
% African-American
% Other
Education high school grad or less
Education,
Health status, good, very good / excellent
Poor medication adherence (Morisky)
Satisfaction with care, very (highest score)
Ever restricted medication due to cost
PACIC mean (sd)
PACIC,
( d)
Medication cost burden (CRAB), mean (sd)
Diabetes diagnosis
Major depression diagnosis
Other chronic health condition
50.1 (17.4)
65.7%
38.9%
50.1%
4.7%
6.3%
45 2%
45.2%
74.6%
45.3%
66.3%
28.9%
3 02 (1.25)
3.02
(1 25)
1.50 (0.82)
27.0%
12.9%
51.1%
Multivariable models:
CRAB was inversely associated with the total
PACIC score (OR = 1
1.17)
17)
i.e., ↑ CCM delivery, ↓ cost-related
cost related problems
also, higher subscales scores for:
patient activation (OR = 1.26)
problem solving (OR = 1.16)
practice design (OR = 1.26)
1 26)
Figure 1: Multivariable Model Predicting No CRAB
PACIC Total (OR=1.17)
Patient Activation (OR=1.26)
Care Coordination (OR=1
(OR=1.05)
05)
Problem Solving (OR=1.16)
Goal Setting (OR=1.04)
P ti D
Practice
Design
i (OR
(OR=1.26)
1 26)
0
02
0.2
04
0.4
06
0.6
08
0.8
10
1.0
12
1.2
14
1.4
16
1.6
18
1.8
20
2.0
Odds Ratio (OR) – per point change in PACIC score
* models controlled for age, gender, ethnicity, and education
Discussion
Patients experiencing care more consistent with the
chronic care model had lower cost-related
cost related burden
Being actively involved in clinical decisions and provided
i f
information
ti about
b t their
th i care → added
dd d b
benefits
fit
While prevalence and factors influencing poor adherence
are widely understood, cost burdens are less appreciated
Efforts to develop highly activated
activated, involved patients can
help mitigate ramifications of financial pressures
Community providers should better recognize and discuss
medication cost burdens while focusing treatment efforts
in accordance with chronic care treatment delivery
Overlap Between CCM and PCMH
Comprehensive
First Contact
Primary Care
SelfManagement
Support
Decision
Support
Clinical
Information
Systems
Patient-Centered
Medical Home
Community
Linkages
Wagner CCM
What s
What’s
Included?
(Infrastructure)
How Much
Used?
(Extent)
What
Evidence
Functions?
(Implementation)
Comparing the PCMH and CCM
THE PCMH Standards
THE CCM
1. Access & Communication
Delivery System Design
2. Patient Tracking & Disease Registry Clinical Info Systems & Decision Support
3. Care Management
Decision Support & Delivery System Design
4. Self-Management Support
Self-Management Support
5. Electronic Prescribing
g
Clinical Information Systems
y
6. Test Tracking
Delivery System & Clinical Info System
7. Referral Tracking
Delivery System & Clinical Info System
8. Performance Reporting and
Improvement
Organizational Support & Clinical
Information Systems
9. Advanced Electronic
Communication
Clinical Information Systems
Quantitative Associations: CCM & PCMH
association between patient (PACIC) and provider (ACIC)
assessments of chronic care model: answer - very low
Dr. Parchman and colleagues constructed a PCMH “score”
f
from
provider
id surveys b
based
d upon th
the NCQA categories:
t
i
not recognized (<25), Level I (25 - 49), Level II (50 - 74), or
Level III (75+)
range 3 - 61; mean = 28
28.4;
4; 54% = not; 31% = 1; 15% = 2
** no multivariable association between estimated PCMH &
CCM (p=0.28)
Implications
p
for effective implementation,
p
, reconciling
g
priorities, enhancing therapeutic alliance, etc.
John Zeber, PhD
Veterans
V
t
Affairs
Aff i HSR&D
(VERDICT)
San Antonio, TX
Assistant Professor
UTHSCSA Dept. of Psychiatry
* study supported by
the National Institute of
Diabetes, Digestive and
Kidney Disorders
(R18 DK 075692)
zeber@uthscsa.edu
@
Michael L. Parchman, MD
(study PI)
parchman@uthscsa.edu