Medication Therapy Management: Partnering with Clinical Pharmacists to Improve Patient Outcomes
March 1, 2023
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AUTHORS
Clipper F. Young, PharmD, MPH, CDCES, BC-ADM, BCGP, APh, Associate Professor and Clinical Pharmacist, Primary Care Department, College of Osteopathic Medicine, Touro University California, Vallejo
Jay Shubrook, DO, Professor and Diabetologist, Primary Care Department, College of Osteopathic Medicine, Touro University California, Vallejo
Megan Handel, PharmD, Graduate, Touro University California College of Pharmacy, Vallejo
Vaseekaraan Vijey, PharmD, Graduate, Touro University California College of Pharmacy, Vallejo
Joshua Neumiller, PharmD, CDCES, FADCES, FASCP, Professor, Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane
PEER REVIEWER
Emily Beckett, PharmD, BCPS, Family Medicine Residency Clinical Pharmacist, Family Health Center – Broadlawns Medical Center, Des Moines, IA
EXECUTIVE SUMMARY
A major contributor to morbidity and mortality, medication nonadherence is associated with approximately $100 billion to $300 billion of annual healthcare spending in the United States.
- This review discusses the foundation of medication therapy management (MTM) and how it relates to Medicare Part D, as well as describes the roles pharmacists play in chronic disease management through the provision of MTM to optimize the use of pharmacotherapeutic agents (e.g., safety and effectiveness), promote health, and improve disease management outcomes.
- MTM services are widely underused, as a result, in part, of suboptimal reimbursement for services.
- The MTM service (MTMS) is defined and described in the Medicare Modernization Act of 2003 with three key goals: 1) promoting Medicare beneficiaries’ understanding of appropriate medication use through counseling; 2) detecting any possible adverse drug events; and 3) increasing beneficiaries’ medication adherence.
- To optimize patient outcomes, a model — Comprehensive Medication Management (CMM) — has been developed to help clinical pharmacists streamline the care delivery while collaborating with other healthcare professionals. CMM aims to assess each patient’s medication regimen to ensure each agent (e.g., prescription medication, nonprescription medication, supplement) is safe, appropriate, and effective for its intended purpose and medical condition.
- MTM is a proven healthcare intervention that currently is underused. As our population ages and the burden of adults living with chronic diseases skyrockets, we need strategies to help people live well to manage these conditions. MTM is one such strategy. Primary care providers often are overwhelmed with the management tasks to be completed in short office visits. Team-based care that includes the pharmacy team and MTM has been shown to improve the quality of care, patient satisfaction, and safety while reducing the treatment burden of other healthcare professionals.
The majority of American adults have at least one chronic disease, often requiring the use of multiple chronic medications. Unfortunately, adherence to chronic medications often is suboptimal, leading to inadequate management of chronic conditions and the risk for morbidity and mortality. Accordingly, medication nonadherence is considered a leading cause of death in the United States. With such a high prevalence of chronic conditions and risks for medication nonadherence, pharmacists can address this public health concern by conducting medication therapy management (MTM).
This review discusses the foundation of MTM and how it relates to Medicare Part D, as well as describes the roles that pharmacists play in chronic disease management through the provision of MTM to optimize the use of pharmacotherapeutic agents (e.g., safety and effectiveness), promote health, and improve disease management outcomes. Unfortunately, MTM services are widely underused because of suboptimal reimbursement for services. By summarizing concepts relating to MTM, illustrating the implications of MTM services, and deliberating on the barriers to implementation, this article provides a comprehensive view of the current state of MTM. It highlights the benefits clinical pharmacy services may offer to address the challenges patients and clinicians face.
Introduction
Medication Therapy Management: What Is It and Why Should Healthcare Providers Know More About It?
MTM is a service that pharmacists and other healthcare professionals provide to optimize therapeutic outcomes via a patient-centered approach.1 MTM focuses on reviewing a patient’s medication regimen to ensure the individual is on the right drug, with the right dose, at the right time, and via the right route, analyzing the safety and effectiveness of the medication regimen.
The MTM service (MTMS) is defined and described in the Medicare Modernization Act (MMA) of 2003 with three key goals: 1) promoting Medicare beneficiaries’ understanding of appropriate medication use through counseling; 2) detecting any possible adverse drug events; and 3) increasing beneficiaries’ medication adherence.2 MTM programs provide services to patients with chronic conditions, such as type 2 diabetes, hyperlipidemia, hypertension, and heart failure, who are taking multiple drugs covered by Medicare Part D plans and are identified as likely to incur high costs for covered Part D drugs.2 The MMA of 2003 requires each Part D sponsor to establish an MTM program in their benefit structure for Medicare Part D beneficiaries. Aiming to increase enrollment, the minimum eligibility threshold for 2010 and after was set to be patients with at least three chronic conditions, eight covered drugs, and $3,000 in annual Part D drug cost.3 Title 42 CFR Part 423 Subpart D establishes criteria for Medicare Part D MTM programs, requiring sponsors to submit their program descriptions to the Centers for Medicare and Medicaid Services (CMS) for review and approval.4 With medication nonadherence identified as the fourth leading cause of death in the United States, pharmacists can alleviate medication nonadherence by conducting MTM sessions.5
Methods
A PubMed literature search was conducted to find relevant articles and studies. The search terms used were “medication therapy management,” “chronic disease management,” “MTM service/delivery,” “diabetes management,” “hypertension management,” “Medicare Part D,” etc. When performing PubMed searches, the date was limited to 10 years prior, knowing some historical contents of MTM would need to be included in this review article. The identified studies from PubMed were included based on the predetermined outline for the review; the studies/articles that fit the themes of the outlined sections were included in the review. Each selected article then was reviewed to extract relevant data and contents. Additional information (for example, medication package inserts, disease treatment guidelines, and MMA of 2003) and articles were identified through Google searches and Google Scholar searches.
MTMS and Its Relationship with Pharmacists
Although other qualified healthcare providers can participate in the provision of MTMS, the MMA specifically identifies pharmacists as MTM providers.2 In addition, the CMS recognizes pharmacists as MTMS providers and considers MTM programs to function as “quality assurance, drug utilization review, or fraud, abuse, and waste control measures.”6 The American Pharmacists Association (APhA) surveyed MTM programs under Medicare Part D; the results revealed that the plans that included face-to-face interactions in their MTM programs would use pharmacists as their primary MTM providers.7
The 2018 CMS fact sheet on MTM programs revealed that all existing Medicare Part D MTM programs include pharmacists to deliver MTMS.8 The success of MTM delivery hinges on pharmacists’ scope of practice, which has continuously been expanded by in-state pharmacy laws. Collaborative practice agreements (CPAs) with a clinical practice guideline-driven, evidence-based approach allow pharmacists to modify patients’ medication regimens (e.g., initiation, titration, discontinuation) without direct physician oversight; in addition, CPAs in some areas support pharmacists to bill for the patient care services they provide.9
To optimize patient outcomes, a model — Comprehensive Medication Management (CMM) — has been developed to help clinical pharmacists streamline the care delivery while collaborating with other healthcare professionals.10 CMM aims to assess each patient’s medication regimen to ensure each agent (e.g., prescription medication, nonprescription medication, supplement) is safe, appropriate, and effective for its intended purpose and medical condition.10 The process of care used by clinical pharmacists in team-based practice is:
- patient assessment (e.g., review a patient’s medical record and prioritize patient problems);
- medication therapy evaluation (e.g., assess the current medication regimen and identify medication-related issues);
- plan development and initiation (e.g., formulate a plan to address the identified, patient-specific problem list);
- monitoring and follow-up (e.g., ongoing assessment to refine and manage the care plan).11
Implications of MTMS
Results Achieved: Individual-Level Economic and Clinical Implications
A major contributor to morbidity and mortality, approximately $100 billion to $300 billion of annual healthcare spending in the United States are associated with medication nonadherence.5,12,13 Pharmacists are in the position to improve medication adherence and reduce medication-related adverse events, thus enhancing the management of chronic conditions. Through generating a list of medications, identifying the ones with potentially low adherence, and addressing identified medication-related adverse events, during the MTM encounters patients are not only advised regarding the reasons they are taking certain medications but also educated about their chronic disease states, thus contributing to improved medication adherence. More than 1.5 million preventable medication-related adverse events occur in the United States every year, and MTMS reduces drug-related adverse events by 50% to 60% and avoids $45 billion in direct healthcare costs.14,15
A study conducted by Ward et al showed that participants who received a telephonic comprehensive medication review (CMR) achieved an average reduction in total all-cause healthcare expenses of $3,680 per member, while participants who did not participate in the telephonic MTM program incurred an average increase of $393 per member.16 The difference in average expenses between the two groups was more than $4,000 per member.16 In addition, MTMS significantly increased medication appropriateness, improved the percentage of prescribed medications taken, and increased the percentage of patients achieving a threshold adherence level.17 With help from pharmacists, MTM participants might be able to lower the cost of their medications by finding more effective alternatives or being enrolled in patient assistance programs.
Numerous studies have shown positive results from pharmacist-led MTMS on measures of chronic disease management.18-22 Table 1 summarizes studies capturing the positive health outcomes/benefits as a result of pharmacist-led MTMS provided to patients with chronic conditions. Studies conducted on this topic ranged from single chronic conditions (e.g., diabetes and hypertension) to multiple chronic conditions with a focus on patient safety or patients seeking medical attention in primary care clinics.
Table 1. Summary of Health Outcomes Provided by Pharmacist-Led MTMS |
|||
Disease State/Study Focus |
Chronic Disease Management Outcomes as the Result of Pharmacists’ MTMS Interventions |
Scale |
Duration/Timeframe |
Single Chronic Conditions |
|||
Diabetes |
Mean hemoglobin A1c 0.4% reduction (P = 0.002); influenza immunization rate increased 33%; eye exam rate increased 24%; foot exam rate increased 40% (with a mean of 14.8 months in the program)23 |
573 patients (Ten City Challenge with a quasi-experimental observational study) |
Participants were engaged in the program for an average of 14.8 months. |
Diabetes |
Hemoglobin A1c reduction as the result of pharmacists’ interventions (1.00 ± 0.28%; P < 0.001); no such reduction seen in controls (0.28 ± 0.29%; P = 0.335)24 |
2,247 patients (analyzed in a meta-analysis combining data from 16 studies) |
The meta-analysis was inclusive of multiple pharmacist-led interventions of varying intensity and duration. |
Diabetes |
Reductions in mean hemoglobin A1c (-0.8% from baseline at six months; P < 0.0001), lipid levels |
12 community pharmacies with 187 participants (Asheville Project) |
Positive outcomes were observed at six months and beyond. |
Hypertension |
Systolic blood pressure significantly reduced (-10.7 ± 11.6 mmHg; P = 0.002) with pharmacists’ interventions while controls’ blood pressure remained unchanged25 |
2,247 patients (analyzed in a meta-analysis combining data from 13 studies) |
The meta-analysis was inclusive of multiple pharmacist-led interventions of varying intensity and duration. |
Heart failure |
Reduction in hospitalization as the result of heart failure exacerbation (OR, 0.69; 95% CI, 0.51-0.94)26 |
2,060 patients (combining data from a systematic review of 12 studies) |
The meta-analysis was inclusive of multiple pharmacist-led interventions of varying duration (six to 12 months). |
Study Focus |
|||
Multiple chronic conditions |
Resolving ~80% of 917 identified drug therapy-related problems; saving $1,123 per patient on claims relating to medications and $472 per patient on hospital-related expenses22 |
Nine pharmacists worked with 88 Medicaid patients in Connecticut |
Participants had an initial 60- to 75-minute consultation with the pharmacist and were eligible for five follow-up appointments at monthly intervals (20-40 minutes each). |
Economic effects on health outcomes |
Reduction in drug expenditures or lengths of hospitalization linked to pharmacists’ technical interventions or services27 |
126 studies included in a systematic review |
Twenty studies showed favorable results from pharmacist-provided care (a majority of these studies supporting cost reduction); studies included were with varying study lengths. |
Primary care clinics |
Improvement in mean change in hemoglobin A1c (-0.88%; 95% CI, -1.15 to -0.62; P < 0.001), systolic blood pressure (-5.72 mmHg; 95% CI, -7.05 to -4.39; P < 0.001), and LDL cholesterol (-18.72 mg/dL; 95% CI, -34.10 to -3.36; P < 0.017) in intervention groups when compared to controls28 |
38 studies; majority of included studies enrolled participants with cardiovascular disease |
The systematic review and meta-analysis included multiple pharmacist-led interventions of varying intensity and duration. The majority of interventions involved medication review (86.8%), with or without other activities, delivered collaboratively with the primary care providers. |
MTMS: medication therapy management service; OR: odds ratio; CI: confidence interval; LDL: low-density lipoprotein |
|||
Program-Level Hurdles: Challenges in Implementation and Implications for Healthcare Policy
Although clinical and economic benefits from pharmacist-led MTMS have been demonstrated through various studies, the implementation of such much-needed services has met many challenges and barriers. Several challenges stem from low recruitment rates, potential patients declining enrollment visits, lack of interest from potential patients, and primary care providers not responding to pharmacists’ recommendations.29 The APhA Medication Therapy Management Digest also discussed the barriers that the profession has been facing in the implementation of MTMS:30
- lack of healthcare insurance plans (other than Medicare Part D plans) covering MTMS-related fees (the greatest barrier);
- inadequate time allotted for pharmacists to perform MTMS (which connects to the first barrier);
- insufficient staff support, high no-show rates, and low patient load for MTMS.
The Agency for Healthcare Research and Quality (AHRQ) conducted a systematic review in 2014; the results pointed to the effectiveness of MTMS in achieving consistent outcomes that had not been supported by adequate evidence, which partly was the result of variation in MTMS implementation and delivery.31 Another study identified that the MTM practice’s maturity level influences its delivery and quality, thus providing evidence that potentially can lead to policy changes in support of unifying the chronic care model (CCM), enhancing MTMS implementation and delivery, and stimulating program/practice maturation.32 A recommendation worth noting here is the emphasis on quality of services provided rather than completion/quantity, encouraging MTMS delivery to adopt a value-based model for optimizing care for individuals, improving health for the population, and reducing healthcare costs.32,33
Discussion and Application of MTM
The essential role of pharmacists worldwide is evolving rapidly, with a continuous push to take on a clinical role combining a background in pharmacotherapy. MTM services have been shown to improve health outcomes — enhancing the effectiveness and safety of pharmacotherapies — while reducing the overall healthcare-associated costs (e.g., unscheduled, urgent medical appointments and emergency department visits). Although many healthcare professionals with the knowledge of and understanding of pharmacotherapies can provide MTM services, clinical pharmacists are the ideal healthcare professionals to deliver these services. Clinical pharmacists have been trained to develop a unique body of knowledge and a set of skills for making clinical judgments for optimizing the use of medications.
The provision of MTM services benefits patients by reducing medication-related hospital admissions. A literature review published in 2020 with 54 studies on medication-related hospital admissions reported that the incidence of medication-related hospital admissions varied significantly depending on definitions used to identify medication-related admissions and methods used, with reported hospital admission rates because of adverse drug events (ADEs) ranging between 0.5% and 19.3%, depending on the definition used in the different studies.34
The review identified significant risk factors for medication-related hospital admissions or readmissions, such as high-risk medications, polypharmacy, therapy non-adherence, older age, comorbidities, renal disease, congestive heart failure, cognitive impairment, and length of hospitalization.34 Most of the identified risk factors can be addressed by providing MTM services to reduce medication-related hospital admissions.
Transitions of Care: Transitioning Out of the Hospital
Most hospitals provide discharge consults or transitions of care (TOC) when a patient is being discharged. One of the many outcomes from an MTM session is the clear and accurate documentation of the medication regimen and its associated analysis, so the TOC pharmacists are in the best position to ensure, at the point of discharge, the continuity of the medication regimen will be accomplished outside of the hospital.
The National Board of Medication Therapy Management (NBMTM) states that using MTM services in the TOC setting has been shown to improve patient outcomes.35 Improvement in patient outcomes partly is the result of patients’ better understanding of their medications upon discharge and transferring of accurate information to the next care setting (e.g., skilled nursing facilities, primary care clinics, etc.). Specifically, MTM services are provided to patients whose chronic conditions are managed on multiple maintenance medications to prevent subsequent hospital admissions.
In 2005, The Joint Commission recognized medication reconciliation as a National Patient Safety Goal (NPSG), focusing on medication management and medication safety.36
Examples of MTM services within TOC:37
- In Johns Hopkins Medicine, the inpatient pharmacy team identifies patients at discharge for post-discharge MTM appointments.
- Within the University of Utah Hospitals and Clinics, a daily list with all discharged patients is sent to the MTM pharmacist team; the team then reviews discharge records and schedules post-hospitalization phone appointments to address any medication-related concerns.
- At the Hennepin County Medical Center, Minneapolis, MN, the TOC pharmacists perform medication reconciliation for patients at the point of discharge and then follow-up for an MTM appointment, focusing on medications started and discontinued during the hospitalization.
Patients who have received MTM services have their chronic conditions better managed when medications are used appropriately and reviewed periodically by pharmacists.18 MTM can make the medication reconciliation process easier and quicker because MTM evaluates the appropriateness, effectiveness, and safety of each medication, which is a superior review to reconciling a patient’s home medications.
Outpatient Care: Chronic Disease Management for Complex Patients
Community Pharmacy Practice Setting
Community pharmacists are the most accessible healthcare professionals in the industry, serving hundreds of patients each day when they present to the pharmacy to pick up their prescribed and over the counter (OTC) medications. As mentioned previously, the CMS MTMS regulations have provided pharmacists with a clear target population for delivering MTM services: individuals living with multiple chronic conditions, taking multiple Medicare Part D covered medications, and having a high likelihood of incurring high annual costs.38 Following this guidance, community pharmacists have the resources to identify potential patients who might benefit from MTM services, e.g., those who do not adhere to medications, those who receive medications from multiple providers, those who receive medications that require routine laboratory monitoring to ensure safety and effectiveness, and those who recently have been discharged from a hospital.
MTM services come in different shapes and forms. Practically speaking, community pharmacists performing a simple drug-drug interaction check when patients purchase OTC medications at a pharmacy is a form of MTM services, especially for clinically complex patients taking multiple chronic medications. This simple task might lead to a comprehensive medication review to identify medication therapy problems, e.g., taking a medication without an indication, receiving suboptimal drug therapy, taking incorrect doses (either too low or too high), having problems adhering to drug therapy, and experiencing adverse effects and drug-drug/drug-food interactions.
Although a comprehensive electronic medical record often is not available at the community pharmacy setting to supplement the delivery of MTM services, there are ways to use the available information to review patients’ pharmacotherapies, potentially leading to recommendations that patients can bring to their prescribers to improve the safety and effectiveness of medication use.
Ambulatory Primary Care Clinic Setting
Some healthcare organizations have used clinical pharmacists and are successfully sustaining patient health outcomes. For example, Kaiser Permanente, Veterans Affairs, and Indian Health Services are the most prominent healthcare systems that have used clinical pharmacists to provide MTM services and chronic disease management for conditions such as hypertension, diabetes, hyperlipidemia, heart failure, mental health conditions, and anticoagulation. The clinical activities provided by pharmacists in delivering MTM services vary depending on the resources available, but there is a set of basic skills — “CARE” — required of the clinical pharmacists:39
- Collecting patient-specific information relevant to understanding the patient;
- Assessing the available subjective and objective data, leading to a problem list and a care plan;
- Reporting to supervising physicians regarding patient data, problems identified, and recommendations with rationale;
- Educating patients and caregivers on treatment plans, medications, and other health-related modifications.
Many clinical pharmacist-driven clinics have established CPAs with primary care providers for providing clinical services. Although some of these CPAs are general, many agreements are disease-specific, allowing in-depth assessment of the specific chronic condition and supporting pharmacotherapeutic modifications to optimize chronic disease management. While pharmacists slowly are being recognized to perform clinical activities, the scope of practice is different in different states; thus, the authors encourage any pharmacists wishing to provide MTM services to consult with their state board of pharmacy to ensure all the intended activities are covered under the scope of pharmacy practice.
Barriers to MTM Services Implementation in the Outpatient Setting
Although there are clear benefits for patients to receive MTM services as demonstrated in the clinical case (see related section, “Application of Medication Therapy Management: A Complicated Patient”), implementation of MTM services often is met with barriers.
Incomplete medical information. This is an operational barrier in the sense that when MTM services are provided in a community pharmacy, a pharmacist often reviews a patient’s medication regimen without having access to laboratory results, complete past medical history, and the primary care provider’s clinical notes. For this reason, the quality of MTM services provided often depends on how much information is given to the pharmacist.
Limited implementation of recommendations. Community pharmacists, in most cases, do not have any CPAs established with primary care providers, making it difficult for the pharmacists to implement any clinical recommendations relating to patients’ pharmacotherapies. This barrier is a result of the suboptimal integration of community pharmacists as members of the healthcare team since they often operate in a “silo.”40 The outcomes from many MTM encounters, thus, often are patient consultation on medications, medication reconciliation, and checking for medication adherence, putting the patients in charge of relaying the recommendations to their primary care providers.
Incompatibility with pharmacy workflow. Very little to no formal organizational infrastructure and staffing support is established within community pharmacies to facilitate MTM services. Some studies have revealed that community pharmacists in North America expressed issues integrating MTM services with their current workflow, resulting in the lack of MTM services expansion despite the clear benefits.41,42
Overall Implementation Barriers
Patient engagement. Patients seldom are being referred by physicians and other healthcare providers for MTM services.43 Most patients do not know what MTM services are; thus, they do not understand the benefits of receiving such services. This barrier has its roots in patients not being fully aware of pharmacists’ expanded role on the healthcare team, e.g., working with other clinicians to manage pharmacotherapies or to make medication recommendations. In addition, patients are concerned about the cost of MTM services; a study revealed patients’ mixed willingness to pay for the services.44
Delivering MTM services as a business model. Because of the low volume and low reimbursement for MTM services, it is very difficult to make the delivery of MTM a sustainable business model.45 Outside of Medicare Part D, broad coverage for MTM delivery hardly exists, with Medicaid programs seeing the value of MTM, but private health insurance payers not seeing the benefits nor compensating for MTM services delivered.46
Future Directions and Potential Implementation Solutions
To establish sustainability and positive outcomes from MTM services, a series of potential solutions at the health system level has been proposed for consideration.
Integrating MTM services into the pharmacy workflow. Incorporating MTM services into a busy community pharmacy’s daily workflow is very challenging, since the main responsibility of the pharmacy team is to dispense medications. For that reason, clear delineation of roles among team members to support MTM delivery is important; for example, pharmacy technicians help with reconciling medication lists, making reminder phone calls, and completing related documentation, which, in turn, allows pharmacists to spend more time on clinical tasks to expand their efficiency in MTM delivery.
Integrating MTM services into the healthcare team. In the ambulatory primary care setting, MTM services delivered by a clinical pharmacist can be integrated into a medical appointment with the primary care provider as a means not only to supplement the appointment but also to reduce some of the tasks relating to medications. Kaiser Permanente, Veterans Affairs, and the Indian Health Service each have developed a model for integrating MTM services into the existing healthcare services, allowing clinical pharmacists to maximize their scope of practice for the benefit of the patients they serve.
Enhancing patient engagement in MTM-related and medication adherence public health campaigns. Since one of the roadblocks is lack of awareness of MTM services among patients/the public, initiating tailored public health campaigns for promoting MTM in chronic disease management has been suggested.47 An example of such a campaign is Script Your Future, encouraging patients with chronic health problems, such as diabetes, chronic obstructive pulmonary disease, asthma, hypertension, and/or hyperlipidemia, to take medications as directed. A focus of this campaign has been urging patients to understand their conditions and medications and starting conversations with healthcare professionals about their medications.48
The core idea of this campaign aligns well with one of the MTM outcomes: discussing pharmacotherapeutic options to optimize the safety and effectiveness of their usage. In addition, providing patients with incentives has been documented as a beneficial strategy for recruiting patients for the services.49
Although the implementation of MTM services has met many barriers, leading to the limited uptake at a broad scale, the benefits of MTM services repeatedly have been demonstrated to improve clinical and economic outcomes. It is a matter of time for MTM services to be integrated into all aspects of patient care with the goal to maximize the safety and effectiveness of pharmacotherapy and to reduce the sequelae of chronic conditions.
Application of Medication Therapy Management: A Complicated Patient
Patient Case: Subjective and Objective Information
Patient J.M. is a 69-year-old Hispanic, widowed female and presents to her primary care provider (PCP) for a follow-up appointment regarding her hypertension management after recently increasing her lisinopril dose (one month ago). During the office visit, the patient’s PCP asks whether she has anyone to help her with her disease and medication management. The PCP is concerned about J.M.’s ability to keep up with her medications and even more concerned about her hemoglobin A1c (HbA1c) level at 10%.
The patient’s insurance benefit covers medication therapy management (MTM) services. The PCP, therefore, refers the patient to the clinical pharmacist in the clinic for MTM. The patient is asked to bring all her medications to her MTM appointment.
Past Medical History
J.M.’s past medical history includes type 2 diabetes, hypothyroidism, hypertension, atrial fibrillation, Class II heart failure with reduced ejection fraction (HFrEF) Stage C, chronic kidney disease (CKD) Stage 3aA3 (proteinuria), history of ischemic stroke, gastroesophageal reflux disease (GERD), major depressive disorder, and insomnia.
Social History
J.M. lives at home alone, but her son drives her to her appointments. She likes to walk her dog around her neighborhood for approximately 30 minutes every morning.
Self-Monitoring at Home
J.M.’s morning fasting blood glucose levels have been in the lower 200s recently, and she does not report any recent episodes of hypoglycemia. However, she has not been monitoring her blood pressure since she does not have a blood pressure monitoring device.
Prescription Medications
- Metformin 1,000 mg, one tablet twice daily
- Pravastatin 20 mg, one tablet daily in the evening
- Lisinopril 40 mg, one tablet daily
- Metoprolol tartrate 50 mg, one tablet twice daily
- Spironolactone 25 mg, one tablet daily in the morning
- Dabigatran 150 mg, one capsule twice daily
- Ranitidine 150 mg, one tablet twice daily
- Citalopram 40 mg, one tablet daily
- Levothyroxine 50 mcg, one tablet daily
Over-the-Counter Medication
- Melatonin 3 mg
Vitals
Blood pressure, 122/78 mmHg (previous visit: 145/95 mmHg); heart rate, 68 bpm; height: 65 inches; weight: 68 kg; body mass index: 25
Laboratory Results
Comprehensive Metabolic Panel (Selected Items)
- Potassium: 4.5 mmol/L (normal range: 3.5 mmol/L to 5.0 mmol/L)50
- Sodium: 140 mmol/L (normal range: 136 mmol/L to 145 mmol/L)
- Serum creatinine: 1.1 mg/dL (normal range: 0.5 mg/dL to 1.2 mg/dL)
- Estimated glomerular filtration rate (eGFR): 58 mL/min/1.73 m2 (normal range: > 60 mL/min/1.73 m2)
- Alanine aminotransferase (ALT): 53 units/L (normal range: 4 units/L to 36 units/L)
- Aspartate transaminase (AST): 49 units/L (normal range: 0 units/L to 35 units/L)
Lipid Panel (Selected Items)
- Low-density lipoprotein (LDL): 159 mg/dL (normal range: < 130 mg/dL)
- High-density lipoprotein (HDL): 42 mg/dL (normal range: > 55 mg/dL)
- Triglycerides: 205 mg/dL (normal range: 35 mg/dL to 135 mg/dL)
- Total cholesterol: 232 mg/dL (normal range: < 200 mg/dL)
Complete Blood Count (Selected Items)
- Hemoglobin (Hgb): 13.4 g/dL (normal range: 12 g/dL to 16 g/dL)
- Hematocrit (Hct): 43.3% (normal range: 37% to 47%)
- Platelet count (Plt): 149 × 109/L (normal range: 150 × 109/L to 400 × 109/L)
Other
- HbA1c: 10% (normal range: < 5.7%)
- Fasting plasma glucose: 195 mg/dL (fasting normal range: 70 mg/dL to 110 mg/dL)
- Thyroid stimulating hormone (TSH): 8.3 mU/L (normal range: 0.3 mU/L to 5 mU/L)
- Free T4: 0.5 ng/dL (normal range: 0.8 ng/dL to 2.8 ng/dL)
Urine Sample
- Urine microalbumin to creatinine ratio: 350 mg/g (normal range: < 30 mg/g)
Echocardiogram Evaluation
- Left ventricular ejection fraction: 30%
Risk Score
- CHA2DS2-VASc = 7
Depression Rating Scale
- Patient Health Questionnaire-9 score = 10
The patient brings the following medications to the MTM appointment:
- Metformin 1,000 mg, one tablet twice daily
- Metoprolol tartrate 50 mg, one tablet twice daily
- Spironolactone 25 mg, one tablet daily in the morning
- Furosemide 20 mg, one tablet daily in the morning
- Dabigatran 150 mg, one capsule twice daily
- Ranitidine 150 mg, one tablet twice daily
- Levothyroxine 50 mcg, one tablet daily
- Pravastatin 20 mg, one tablet daily in the evening
- Lisinopril 20 mg, one tablet daily
- Lisinopril 40 mg, one tablet daily
- Citalopram 40 mg, one tablet daily
- Lorazepam 1 mg, one tablet as needed for sleep (last filled one year ago)
- Melatonin 3 mg (OTC)
- Vitamin D 2,000 units (OTC)
Case Discussion: Assessment and Plan
Upon reviewing the medical health record and medications brought in by the patient, the clinical pharmacist identified the following problems:
- The patient still has an old bottle of her previous lisinopril dose (20 mg) as well as three additional medications that are not on her current medication list: furosemide, lorazepam, and vitamin D.
- The patient’s HbA1c and fasting blood glucose (FBG) levels are not at goal (HbA1c goal set at < 8% and FBG goal set at between 100 mg/dL and 150 mg/dL), despite taking the maximum effective dose of metformin. Consider intensifying diabetes pharmacotherapy by adding a sodium-glucose co-transporter 2 (SGLT-2) inhibitor with proven benefits to reduce cardiorenal risks for secondary prevention of stroke, delaying the progression of CKD and proteinuria, and reducing the risk of hospitalization as the result of heart failure.51
- The patient currently is taking metoprolol tartrate; however, studies have shown reduced mortality because of heart failure with the use of metoprolol succinate (an extended-release formulation) in patients with systolic heart failure.52,53
- The patient is taking a low-intensity statin (pravastatin 20 mg), but she is indicated for a high-intensity statin, given her age, type 2 diabetes, and a history of ischemic stroke.51,54 There is an increased risk of QT prolongation in geriatric patients who are taking citalopram with a daily dose higher than 20 mg.55
- There is an increased risk of gastrointestinal (GI) bleeding with the use of dabigatran (Pradaxa) in geriatric patients with decreased renal function.56 In addition, this patient has gastroesophageal reflux disease (GERD), which would increase her risk of GI bleeding even further. Consider changing to apixaban (Eliquis), which has the least risk of GI bleeding compared to other direct oral anticoagulants (DOACs) and warfarin.57
- A home blood pressure monitoring device should be prescribed to the patient so she that can perform daily self-monitoring.
- The patient has been taking vitamin D supplementation on a daily basis; consider rechecking her serum vitamin D level.
- This patient has type 2 diabetes, which has been associated with an increased risk for nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH), which subsequently increases the risk of liver fibrosis and cirrhosis. This patient has elevated AST and ALT. The American Diabetes Association (ADA) Standards of Medical Care 2023 recommends assessment for the presence of NASH or liver fibrosis in those with type 2 diabetes and elevated liver enzymes.51 The first step for assessment is to calculate a Fibrosis-4 (FIB-4) score using a FIB-4 calculator. Her Fib-4 score is 3.12.59 The American Gastroenterological Association (AGA) guidelines consider a 3.12 FIB-4 score at high risk for fibrosis; thus, referral to a hepatologist is warranted.60
- The patient currently is taking levothyroxine 50 mcg daily and expresses that she has been taking this medication first thing in the morning, separating at least one hour from her other medications. Her most recent TSH level was above the TSH goal and her free T4 level was below the T4 goal, indicating that she has not yet reached a euthyroid state.
The following interventions are implemented by the clinical pharmacist step-by-step within two to three follow-up appointments, according to the collaborative practice agreements (CPAs) established between the primary care provider and the clinical pharmacist.
- Educate the patient to avoid keeping old medications and avoid either mixing them with her current medications or potentially taking the wrong medication.
Lisinopril 20 mg: The patient currently is taking lisinopril 40 mg. To avoid confusion and potentially taking the wrong dose, suggest disposing of the lisinopril 20 mg at a proper disposal site.
Furosemide 20 mg: Although furosemide can be used to alleviate symptoms of heart failure, it currently is not being prescribed by her PCP. Unless her PCP has specifically told the patient to use furosemide as needed for heart failure symptoms (which should be notated on her current medication list), suggest disposing of the furosemide at a proper disposal site.
Lorazepam 1 mg: This medication is not recommended for patients 65 years of age or older.60 Explain the risks of using lorazepam to the patient. If the patient confirms that she is no longer taking this medication, suggest disposing of the lorazepam at a proper disposal site.
- SGLT-2 inhibitors are recommended in patients who have established heart failure.2 Of all the SGLT-2 inhibitors, empagliflozin and dapagliflozin both have shown benefits in managing ASCVD, HF, and CKD; each has two Food and Drug Administration-approved indications for reducing the risks of diabetes-associated complications.61,62 Because empagliflozin carries few warnings associated with potential adverse effects, it is the drug of choice for this patient. Consider initiating empagliflozin 10 mg or dapagliflozin 10 mg daily in the morning. Recheck basic metabolic panel (BMP) in two weeks.
- Current studies have shown reduced morbidity and mortality in patients with HFrEF with the use of metoprolol succinate, bisoprolol, or carvedilol.52,53 When converting patients from metoprolol IR to ER formulations, the same total daily dose of metoprolol is used.63 This patient currently is taking 100 mg of metoprolol tartrate daily. Consider switching to metoprolol succinate ER 100 mg daily.
- Because of this patient’s history of ischemic stroke and type 2 diabetes, a high-intensity statin is indicated.51,54 Note, rosuvastatin requires renal adjustment and atorvastatin does not. Consider switching from pravastatin to atorvastatin 40 mg daily.
- Considering the risks associated with citalopram at the current dose, reduce citalopram to the maximum recommended dose in the geriatric population. The patient should then be monitored for any changes in depressive symptoms. Recommendation: Reducing citalopram to 20 mg daily.
- Considering the risks associated with dabigatran (Pradaxa), consider switching to apixaban (Eliquis), which has a lower risk of GI bleeding.57 Recommendation: Switch to apixaban 5 mg twice daily.
- Send a prescription to the patient’s pharmacy for a blood pressure monitoring device.
- Send a laboratory order for rechecking the patient’s serum vitamin D level.
- Considering her multiple chronic conditions with a hypothyroid state, titrating the levothyroxine dose slowly is indicated.64 Recommendation: Increasing levothyroxine to 67.5 mcg daily. Recheck TSH and free T4 levels in six to eight weeks.
Personal Medication List and Medication Action Plan
The deliverables of an MTM session provided for J.M. in writing are a medication action plan (MAP) and a personal medication list (PML). To communicate the medication changes with and outline the implementation steps for the patient, a MAP is developed in meeting specific treatment goals. This document can and should include aspects beyond pharmaceutical care, such as lifestyle modifications and screening assessments.
Figure 1 (bit.ly/3xrqq40) shows a Centers for Medicare and Medicaid (CMS) MAP template.65 In addition, a PML is created to provide a simple and individualized reference of all the current medications, helping J.M. to understand why and how to take her medications. A CMS-recommended format for the PML is included in Figure 2 (bit.ly/3Ir7Wa5).16
Final Thoughts on the Case
During the MTM session, the clinical pharmacist and the patient together make a daily medication schedule that helps J.M. to keep track of when, how, and why she is taking each of her medications. The clinical pharmacist reminds the patient to bring any newly prescribed medications to her future medical visits so her healthcare provider(s) can review the safety and effectiveness of the medications with her, optimizing the efforts in managing her chronic conditions.
After this MTM encounter, the clinical pharmacist shares a clinical note with J.M.’s PCP regarding the recommendations and changes according to the CPAs relating to pharmacotherapy so the entire team is on the same page regarding the updated pharmacotherapeutic plan for future medical appointments. Had the patient continued to take the medications she already was taking in addition to the newly prescribed medications, it is possible that she could experience severe adverse events, e.g., rhabdomyolysis and hyperkalemia. The interventions made during the MTM encounter drastically reduced the risks associated with her medication regimen, which further accounts for why MTM is an effective means to provide optimal care outcomes.
Conclusions
MTM is a proven healthcare intervention that currently is underused. This may be for various reasons, including low levels of awareness. As our population ages and the burden of adults living with chronic diseases skyrockets, we need strategies to help people live well to manage these conditions. MTM is one such strategy. PCPs are overwhelmed with the management tasks to be completed in short office visits. Team-based care that includes the pharmacy team and MTM has been shown to improve the quality of care, patient satisfaction, and safety while reducing the treatment burden of other healthcare professionals.
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The majority of American adults have at least one chronic disease, often requiring the use of multiple chronic medications. Unfortunately, adherence to chronic medications often is suboptimal, leading to inadequate management of chronic conditions and the risk for morbidity and mortality. This review discusses the foundation of medication therapy management, a service that pharmacists and other healthcare professionals provide to optimize therapeutic outcomes via a patient-centered approach.
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