Pharmacy QI initiative ties in with DM

Program targets members on medication

As an adjunct to its disease management programs, ConnectiCare, a regional HMO based in Farmington, CT, has launched a pharmacy quality improvement program to promote the use of medications that are nationally acceptable treatment standards and to identify and prevent potential drug safety adverse events.

As part of this initiative, ConnectiCare identifies and contacts members who aren't taking some of the medications recommended for their conditions or who have been prescribed medications that might not be appropriate.

The health plan's pharmacy quality improvement committee meets monthly to discuss pharmacy quality issues.

One aim of the committee is to tie together a number of quality initiatives in the organization, says Jeffrey Casberg, MS, RPH, director
of pharmacy.

"We coordinate our initiatives. For instance, the pharmacy projects go hand in hand with our health management programs. They're not fragmented," Casberg says.

The program has been highly successful, he adds. For instance, the health plan sent out letters to 3,300 members with LDL cholesterol levels at or above 160 who are in the cardiovascular or diabetes health management programs or who are older than 35).

The letters suggested that the members discuss their level with their physician to determine whether they needed pharmacological therapy or whether they might be able lower their cholesterol with diet and exercise.

Nine months later, when the health plan re-examined the data, 58% of those who received the letters had a 20% or greater reduction in cholesterol level.

If an examination of the pharmacy database turns up members in a disease management program who are not filling prescriptions for a particular medication, ConnectiCare sends them a letter suggesting that they talk to their physician about the medication. The health plan follows up with a letter to the physician alerting him or her that the patients may be discussing their medications on their next visit.

The program targets the members themselves, as opposed to sending the mailing to physicians. The letters explain about medication and ask members to bring their letter and discuss the subject with the physician at their next appointment.

"We have found that we are more apt to get a reaction if we send a letter to a member and ask them to talk to their doctors," says Jay Salvio, BSN, MBA, director of ConnectiCare's Health Management department and a member of the pharmacy quality improvement team. "We identify a topic that we feel is important for members to know about and ask them to discuss it with their physician. We send a companion letter to the physician so both of them are knowledgeable about what we want to accomplish."

When the health plan designed the initiative, committee members were careful not to make it seem like they were telling the physicians how to practice, Salvio adds.

"We don't tell the member they should or shouldn't be taking a certain medication. We suggest that they talk to their doctor and have him evaluate it," he says.

The organization started its pharmacy quality improvement program with an initiative to make sure members with congestive heart failure, diabetes, and post-myocardial infarctions were taking ACE inhibitors or ARBs as suggested by clinical guidelines.

The health plan sent out 2,300 letters to members who had the three conditions but were not filling a prescription for the medications. When it did a follow-up study, it found that 21% of members who were not taking the medications had begun taking them following the letter-mailing campaign.

The next step is to identify members who have gotten at least two letters recommending they take a certain drug and finding out why they haven't responded, then decide what initiatives the health plan should take to help overcome the barriers, Casberg adds.

Here's a look at some of ConnectiCare's other pharmacy quality improvement initiatives:

Elderly drug safety: The health plan sends letters to all members older than age 60 who are taking one or more medication that may not be suitable for older people.

"Our letter sends them a list of the Terrible 20, compiled by the General Accounting Office five years ago. We tell them they're on one of the medications and that there may be a better alternative for people in their age group. The letter suggests that the member discuss it with their physician on their next visit," Casberg says.

In 2002, the health plan sent letters to 757 members who were taking drugs not recommended for older patients. When they remeasured, 60% of the 757 members no longer were taking the drug.

The "Terrible 20" includes medications that cause drowsiness and older medications that have more side effects than a similar, newer ­medication.

"Most are medications that tend to be sedating and put older people at risk for falls and accidents. Some members have been taking the medicines for a long time and simply need to be reevaluated," Salvio says.

Aspirin as a preventive measure:

The health plan has begun an initiative to encourage members to talk to their physician about taking low-dose aspirin as a preventive measure.

The first year, the plan sent a letter to people who had had heart attacks or other cardiovascular events. The second year, it targeted people who could be at risk for an event, such as those with diabetes or those who are older than 50 with diabetes and high lipids.

"While it's well known that aspirin can be helpful in preventing heart disease and heart attack, it's often underutilized. We wanted to get the word out and remind people to discuss aspirin therapy with their physician," Casberg says.