Positive Deviants for Medication Therapy Management: A Mixed-Methods Comparative Case Study of Community Pharmacy Practices

Abstract

Background\n\nMore than 90% of individuals aged 65 years or\nolder in the United States (US) are taking at least one prescription\nmedication, and more than 40% are taking five or more prescription medications.\nThe potential for non-adherence and risk of medication therapy problems (MTPs)\nincreases with the use of multiple medications. \nTo enhance patient understanding of appropriate medication use, improve medication\nadherence, and reduce MTPs, the Centers for Medicare & Medicaid Services\n(CMS) launched Medication Therapy Management (MTM) services as part of Medicare\nPrescription Drug (Part D) policy; however, “best practices” for achieving\npositive MTM outcomes are not well understood.\n\n \n\nObjectives\n\nThis study had two objectives. The first objective was to identify\nand explain reasons for concordance and discordance between a) consistently\nhigh, moderate, and low performing pharmacies and b) pharmacies that improve or\nworsen in performance overtime. The second objective was to generate hypotheses\nfor strategies that contribute to community pharmacies’ ability to achieve\nhigh performance on widely accepted MTM quality measures. \n\nMethods\n\nThis comparative mixed-methods, case study design\nincorporated two complementary conceptual models. First, an adaptation of the\nPositive Deviance (PD) model explains reasons for deviations in MTM quality\nmeasure performance among community pharmacies and informs study design.\nSecond, the Chronic Care Model (CCM) guided data collection and analysis. Data\nconsisted of pharmacy/staff demographics and staff interviews. When\nappropriate, quantitative and qualitative data were analyzed within and across pharmacy\nMTM performance (i.e., high, moderate, low) or change-in-performance (i.e.,\nconsistent, improved, worsened) categories using descriptive statistics and\ncross-tabulation respectively. MTM performance component measures used to\nevaluate and rank pharmacy MTM performance mirrored measures under Domain 4\n(Drug Safety and Accuracy of Drug Pricing) of the 2017 CMS Medicare Part D Plan’\nStar Rating measures. This study was approved by the Institutional Review Board for the Purdue University Human Research Protection Program. \n\nResults \n\nAcross the sample of eligible pharmacies (N = 56), MTM\nperformance composite scores varied by 21.3%. Of the five component scores, the\nComprehensive Medication Review (CMR)\ncomponent score had the highest percent variation (88.3%). Pharmacy staff at 13\npharmacies of the 18 pharmacies selected as case study sites participated in\ninterviews, yielding a 72.2% case pharmacy participation rate. Of the 13\npharmacies, five were categorized as high performers, four were moderate\nperformers, and four were low performers. Of the 39 pharmacy staff approached\nacross all pharmacies, 25 participated in interviews, yielding a 64.1%\nparticipation rate. Interviewees included 11 pharmacists, 11 technicians and\nthree student interns. Eight strategies were hypothesized as positively (7) or\nnegatively (1) contributing to pharmacies’ MTM performance. Hypotheses\ngenerated were organized by CCM elements and included: Delivery System Design (DSD) – Having a high degree of technician\ninvolvement with MTM activities; Inability to meet cultural, linguistic, and\nsocioeconomic needs of patients (negative); Having sufficient capacity to\nprovide CMRs to patients in person compared to telephone alone; Pharmacy staff\nplacing high priority on addressing MTM activities; Clinical Information Systems (CIS) – Faxing adherence-related MTP\nrecommendations and calling providers on indication-related MTP\nrecommendations; Technicians’ use of CISs to collect/document information\nfor pharmacists; Using maximum number of available CISs to\nidentify eligible MTM patients; Health\nSystem Organizations (HSO) – Strong pharmacist-provider relationships and\ntrust. No hypotheses were generated for the remaining three CCM elements.\n\n \n\nConclusions\n\n\nA total of eight strategies were hypothesized as\ncontributing to community pharmacies’ ability to achieve high performance on\nMTM quality measures. Notable strategies were related to three of the six\nchronic care model elements. Future research should engage stakeholders to\nassist with prioritizing hypotheses to be statistically tested in a larger\nrepresentative sample of pharmacies.