The 10th Annual Utah Health Services Research Conference: Clinical and Economic Impact of a Pharmacist-Led Diabetes Collaborative Drug Therapy Management Program in a Medicaid ACO Setting. By: Eman Biltaji; C McAdam Marx; M. Yoo; B. Jennings; J. Leiser - University of Utah College of Pharmacy Health Services Research Conference: March 16, 2015 Patient Centered Research Methods Core, University of Utah, CCTS

1. Clinical and Economic Impact of a
Pharmacist-Led Diabetes Collaborative
Drug Therapy Management Program in
a Medicaid ACO Setting
E. Biltaji1, C. McAdam Marx1, M. Yoo1,
B. Jennings1,2, K. Gunning1,3, J. Leiser3
1. Department of Pharmacotherapy, University of Utah College of Pharmacy;
2. Department of Pharmacy Services, University of Utah Hospitals and Clinics;
3. Department of Family and Preventive Medicine, University of Utah School of Medicine

2. Introduction
• In 2013, the University of Utah Heath Care
(UUHC) and Health Plan established a Medicaid
Accountable Care Organization (ACO).
• Effective management of chronic diseases
including type 2 diabetes mellitus (T2DM) is a
priority of this ACO.

3. CDTM: Overview
• A diabetes Collaborative Drug Therapy
Management (CDTM) 1 program is supported in
the UUHC Community Clinics
– Based on primary care provider’s referral
– Pharmacist working under collaborative practice
agreement with clinic physicians and advanced
practice clinicians
• Prescribe and modify diabetes medication therapy
• Order HbA1c and lipid monitoring tests
• Provide diabetes education
1. McAdam-Marx, C., Dahl A. et al. J Manag Care Pharm. Accepted
for Publication February 2, 2015.

4. CDTM: Previous Analyses
• CDTM has been shown to1
– Improve HbA1c by up to 2.0%
– No change in healthcare utilization for inpatient and
emergency services in the 12-month period after
index date than the prior 12 months
– Total medical charges (SD) were on average
$251(18,174) higher and inpatient charges (SD) were
on average $283 (12,336) lower, but the differences
were not significant.
1. McAdam-Marx, C., Dahl A. et al. J Manag Care Pharm. Accepted
for Publication February 2, 2015.

5. CDTM: Analysis Limitations
• Previous analysis used health system billing
data to estimate economic outcomes
– Does not reflect amount paid
– Does not include economic data for care delivered
outside UUHC
• It is also unknown if Medicaid patients achieve
the same CDTM outcomes, given barriers to
care and self-management.1
1.Call KT, McAlpine DD, et al. Medical care. 2014;52(8):720-7.

6. Objective
Thoroughly evaluate CDTM
impact on economic &
clinical outcomes patients
with T2DM
Pilot study in Medicaid
patients to assess the
feasibility of merging
clinical & claims data

7. Data Source
UUHC
• EMR
• Administrative
data
HealthyU
• Claims data
More
comprehensive
use and cost
data

8. Study Design
• Retrospective cohort study
– 1/1/2008 to 12/31/2012
CDTM vs.
Comparison
HbA1c
Charges
Amt Paid

9. Eligibility Criteria
• Inclusion
– Age ≥18 years with
T2DM and HbA1c
≥7.0%
– Medicaid coverage
any time during the
observation period
– ≥1 HbA1c reading
90+ days after index
date
• Exclusion
– Diagnosis for type 1
diabetes or polycystic
ovary syndrome
(PCOS) without
diabetes diagnosis

10. Index date
Intervention patients:
• First CDTM visit
Comparison patients:
• HbA1c value 6+ months after first activity date
during study period

11. Study Outcomes
• Mean change in HbA1c
– At baseline vs at 6-months follow-up
• Change in UUHC charges
– 6-months pre-index vs. 6 months post-index date
• Change in amount paid by Medicaid
– 6-months pre-index vs. 6 months post-index date

12. Patient Identification Flowchart:
CDTM Group
Adults with T2DM in CDTM program 2008-2012 (N= 305)
Primary Study Cohort
(N=79)
HealthyU Subset (N=46)

13. Patient Identification Flowchart:
Comparison Group
Adults with T2DM treated in a UUHS community clinic
2008-2012
(N=8,900)
Primary Study Cohort
(N=131)
HealthyU Subset (N=67)

14. Baseline Characteristics
Variable
CDTM
N=79
Comparison
N=131
p-value
Age (mean, SD) 53.2 (12.9) 53.9 (13.0) 0.698
Male (n, %) 24 (30.4) 49 (37.4) 0.756
Diabetes Medications (n, %)
Metformin
Insulin
44 (55.7)
60 (76.0)
53 (40.5)
22 (16.8)
0.032
<0.001
HbA1C (mean, SD)
≥8.0% (n, %)
10.31 (1.70)
72 (91.1)
8.63 (1.76)
65(49.6)
<0.001
<0.001
HealthyU Subset (n, %) 46 (58.2) 67 (51.1) 0.319

15. Medications Prescribed vs. Dispensed
52%
33%
78%
15%
54%
30%
52%
15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
CDTM (n=46) Comparison
(n=67)
CDTM (n=46) Comparison
(n=67)
PercentofPatients
Prescribed by UUHC With HealthyU Claim
Metformin
Insulin

16. Change in HbA1c
-2.04**
(n=79) -2.19**
(n=72)
-0.9**
(n=131)
-1.81**
(n=65)
-3
-2.5
-2
-1.5
-1
-0.5
0
All Baseline HbA1c ≥8.0%
ChangeisHbA1C
CDTM Comparison
Paired t-test *p<0.05, **p≤0.001
p≤0.001
p=0.32

17. Mean Inpatient Admissions
0.16
(n=79)
0.15
(n=131)
0.09
(n=79)
0.09
(n=131)
0.43
(n=46)
0.76
(n=67)
1.76
(n=46)
1.73
(n=67)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
CDTM Comparison CDTM Comparison
EDW HealthyU
6 months pre-index
6 months post-index

18. Mean Emergency Department Visits
0.04
(n=79)
0.08
(n=131)
0.05
(n=79)
0.1
(n=131)
3.24
(n= 46)
1.31
(n=67)
3.3
(n= 46)
1.73
(n=67)
0
0.5
1
1.5
2
2.5
3
3.5
4
CDTM Comparison CDTM Comparison
EDW HealthyU
6 months pre-index 6 months post-index

19. Change in Mean Charges for Care
Provided by UUHS
$4,494
$9,528
CDTM
$4,392
$8,887
$6,661
Comparison
-$2,867
-$4,000
-$2,000
$0
$2,000
$4,000
$6,000
$8,000
$10,000
CDTM (n=79) Comparison (n=131) Difference
6-months pre-index 6-months post-index
p=0.396
p=0.212
Paired t-tests
p=0.157

20. Change in Mean Paid Amount by
Medicaid to all Providers
$2,509
$3,346
CDTM
$822
$3,331
$5,227
Comparison
$1,881
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
CDTM (n=46) Comparison (n=67) Difference
6-months pre-index 6-months post-index
p=0.112
p=0.304
Paired t-tests
p=0.636

21. Study Conclusion
• Incorporating claims data provided much larger
estimates of inpatient and ED use
• Comparing prescription orders to claims highlighted
potential primary non-adherence to insulin
• CDTM program was not associated with greater
improvement in clinical outcomes & cost trends vs
usual care

22. Linking Database Conclusion
Benefits
• Expanded cost &
utilization data
• Charges vs. amount
paid
• Prescription orders vs
claims
Limitations
• Reduced “linkable”
cohort size
• Inability to control for
all factors that could
influence outcomes

23. Acknowledgment
• The authors thank Brian Oberg, MBA, for data
management assistance
• At the time of the study, Dr. McAdam-Marx
received funding from the National Cancer Institute
(award no. KM1CA156723). The content is solely
the responsibility of the authors and does not
necessarily represent the official views of the
National Cancer Institute or the National Institutes
of Health.