title: Impact of Environmental Factors on Differences in Quality of Medication Use: An Insight for the Medicare Star Rating System.
abstract: BACKGROUND
  The Medicare star ratings system incentivizes health plan sponsors based on their performance across a measurement system that contains quality measures related to medication use. As health plan sponsors seek to further engage their network providers, specifically network pharmacies, to improve performance on these measures, it is important to consider the effect of environmental factors on the performance of network pharmacies.
  
  
  OBJECTIVE
  To determine the effect of environmental factors on pharmacy quality as measured by (a) medication adherence for noninsulin diabetes medications, (b) medication adherence for renin angiotensin receptor antagonists (RASA), (c) medication adherence for cholesterol medications (statins), and (d) use of high-risk medications (HRM) in the elderly.
  
  
  METHODS
  The EQuIPP database, which contains performance information for pharmacies for a nationwide sample of Medicare beneficiaries, was used for this analysis. Environmental factors included regions or characteristics of a community or county. County-level data was obtained from the Area Health Resource Files, a resource product available from the Health Resources & Service Administration. A logistic regression model was developed with performance as the dependent variable and regions and environmental factors as independent variables. Performance and county characteristics, such as proportion of patients in an age group, race, income, or number of outpatient visits, were classified as high and low based on a median cutoff of nationwide performance scores.
  
  
  RESULTS
  A total of 28,950 pharmacies were included in this analysis. For most measures, the proportion of low-performing pharmacies was significantly higher in the East South Central, Mid-Atlantic, Mountain, Pacific, and West South Central regions. Pharmacies in counties with high median income, high proportion of elderly population (aged > 84 years), high proportion of elderly patients who were white or Hispanic, high proportion of elderly males, and high proportion of elderly urban patients were less likely to have low performance, whereas those with high proportion of elderly African Americans and high density of independent pharmacies were more likely to have low performance (P < 0.05-0.0001).
  
  
  CONCLUSIONS
  This study found that environmental characteristics of a region, including pharmacy and sociodemographic characteristics, explained regional variation in quality measures related to medication use for patient populations served by pharmacies. This evaluation serves to further inform the discussion regarding case-mix adjustment of quality measures and provides information that may be important to further refine intervention strategies for pharmacies and pharmacists who serve certain regional populations. Additionally, pharmacies in greatest need of support for quality improvement may be those who serve populations that are predominantly low income and elderly African American.
  
  
  BACKGROUND
  Desai's postdoctoral fellowship was funded by Pharmacy Quality Solutions for conducting this study and writing the manuscript. Nau and Conklin are employed by Pharmacy Quality Solutions. An earlier version of this research was presented as a poster at the Annual Meeting of the Academy of Managed Care Pharmacy; San Diego, CA; April 7-10, 2015. Study concept and design were contributed by Conklin, Nau, Desai, and Heaton. Desai and Conklin took the lead in data collection, assisted by Nau and Heaton. The manuscript was primarily written by Desai and Heaton, with assistance from Conklin and Nau. All authors contributed to data interpretation and manuscript revision.
authors.affiliation: 1 James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, Ohio.
authors.forename: Vibha
authors.initials: V
authors.lastname: Desai
authors.affiliation: 2 Pharmacy Quality Solutions, Durham, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Nau
authors.affiliation: 2 Pharmacy Quality Solutions, Durham, North Carolina.
authors.forename: Mark
authors.initials: M
authors.lastname: Conklin
authors.affiliation: 1 James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, Ohio.
authors.forename: Pamela C
authors.initials: PC
authors.lastname: Heaton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003157:Community Pharmacy Services / Q000592:standards*; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000453:epidemiology*; D005260:Female; D006272:Health Facility Environment / Q000592:standards*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007345:Insurance Claim Review / Q000592:standards; D008297:Male; D054524:Medicare Part D / Q000592:standards*; D055118:Medication Adherence; D054539:Medication Therapy Management / Q000592:standards*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
chemical_list: D007004:Hypoglycemic Agents