title: Evaluation of the first year of a pilot program in community pharmacy: HIV/AIDS medication therapy management for Medi-Cal beneficiaries.
abstract: BACKGROUND
  The advent of combined antiretroviral therapy (ART) has increased treatment effectiveness but created new challenges for patients infected with human immunodeficiency virus (HIV) and for community pharmacists managing patients' drug therapy. The ability of pharmacist-provided medication therapy management (MTM) services to increase medication adherence, improve health outcomes, and reduce overall medical costs has been demonstrated in community pharmacies for chronic diseases such as diabetes and hypertension. However, the effectiveness of pharmacist-provided MTM services in HIV/acquired immune deficiency syndrome (AIDS) has not been well studied. In January 2005, a pilot program to evaluate MTM services for patients with HIV/AIDS began in California, allowing 10 HIV/AIDS specialty pharmacies to receive compensation for the MTM services that they provided to HIV/AIDS patients.
  
  
  OBJECTIVE
  To examine the first year of the HIV/AIDS pharmacy MTM compensation pilot program, which described and compared pilot and nonpilot pharmacies with respect to (a) patient characteristics; (b) intermediate outcomes including type and number of ART medication regimens used, rates of adherence and excess medication fills for ART, use of contraindicated ART regimens, and occurrence of opportunistic infections; and (c) pharmacy and medical costs.
  
  
  METHODS
  This was a cohort study examining 2005 Medi-Cal pharmacy and medical claims data for patients with HIV/AIDS who were served by pilot pharmacies versus other pharmacies. The HIV/AIDS patients were Medi-Cal beneficiaries aged 18 years or older as of January 1, 2005, who were continuously enrolled from January 1, 2004, through December 31, 2005, and diagnosed with HIV/AIDS, identified by receipt of at least 1 ART prescription and at least 1 medical claim with a diagnosis (primary or secondary) of HIV/AIDS (ICD-9-CM code 042.0) during both the index period (the year before pilot program implementation, 2004) and the intervention period (the study year, 2005). The only difference in the inclusion criteria for the 2 cohorts was that the pilot pharmacy patients were required to have filled 50% or more of their antiretroviral prescriptions in 2005 at 1 of the 10 pilot pharmacies. Adherence was defined as a medication possession ratio (MPR) of 80%-120% and excess medication fills as MPR greater than 120%. Comparisons were made between groups using bivariate statistics (Pearson chi-square for categorical variables and t-tests for continuous variables). For comparisons of costs, generalized linear models assuming a gamma distribution and log link function were used; predictor variables for the models included age, gender, race/ethnicity, and dual coverage under Medicare.
  
  
  RESULTS
  A total of 7,018 HIV/AIDS patients in the Medi-Cal population were identified as meeting the study criteria. Of these, 19.3% (n=1,353) were pilot pharmacy patients. The demographic profile of pilot pharmacy patients was similar, but not identical, to that of patients receiving medications at other pharmacies. A larger percentage of pilot pharmacy patients were on protease inhibitor-based ART medication regimens (63.8% vs. 54.8%, P<0.001), remained on a single type of ART therapy throughout the study year (56.8% vs. 34.2%, P<0.001), and were classified as adherent (56.3% vs. 38.1%, P<0.001), compared with other pharmacy patients. Fewer pilot pharmacy patients used contraindicated regimens (11.6% vs. 16.6%, P<0.001) or had excess medication fills (19.7% vs. 44.8%, P<0.001). The rate of opportunistic infections did not differ significantly between groups (28.2% vs. 26.1%, P=0.121). The total mean (standard error) annual health care cost per patient was 10% higher in pilot pharmacies than in other pharmacies ($40,596 [$889] vs. $36,937 [$479], P=0.001); driven by use of (a) medications (primarily non-ART medications) and (b) mental health services. Payment from the California Department of Health Care Services for MTM services averaged $1,014 per pilot pharmacy study patient.
  
  
  CONCLUSIONS
  Study findings for the first year of the MTM program suggest that the pilot pharmacy patients received more appropriate HIV treatment. The degree to which these differences are affected by selfselection of patients into the pilot pharmacies is unknown. Longer-term outcomes and costs of the pilot program will be examined when data for subsequent years are available.
authors.affiliation: University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, Mail Code 0714, La Jolla, CA 92093-0714, USA. janhirsch@ucsd.edu
authors.forename: Jan D
authors.initials: JD
authors.lastname: Hirsch
authors.forename: Ashley
authors.initials: A
authors.lastname: Rosenquist
authors.forename: Brookie M
authors.initials: BM
authors.lastname: Best
authors.forename: Teresa Ann
authors.initials: TA
authors.lastname: Miller
authors.forename: Todd P
authors.initials: TP
authors.lastname: Gilmer
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology; D000163:Acquired Immunodeficiency Syndrome / Q000150:complications / Q000188:drug therapy / Q000191:economics; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D003157:Community Pharmacy Services / Q000458:organization & administration* / Q000592:standards; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D016014:Linear Models; D008297:Male; D008484:Medicaid / Q000191:economics; D054539:Medication Therapy Management / Q000458:organization & administration / Q000592:standards*; D008875:Middle Aged; D018579:Patient Selection; D010595:Pharmacists / Q000458:organization & administration; D010865:Pilot Projects; D014481:United States; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents