TABLE 3.
Comparison of Utilization and Adherence Gaps (Per Annum) Within Subgroups Identified Using Current and Novel Claims-Based Case-Finding Criteria
| Subgroups of patientsa | N (% of sample) | Inpatient admissions (mean ± SD) | ED visits (mean ± SD) | Patients with 1+ Rx gapsb n, rounded (% of subgroup) |
|---|---|---|---|---|
| Entire cohort | 1,541,873 (100) | 0.03 ± 0.22 | 0.17 ± 0.56 | 142,800 (9.3) |
| MTM eligibility criteriac | ||||
| ≥ 2 conditions, ≥ 2 medications, > $3,017 annual medication cost | 224,602 (14.6) | 0.19 ± 0.52 | 0.48 ± 1.05 | 55,200 (24.6) |
| ≥ 3 conditions, ≥ 8 medications, > $3,017 annual medication cost | 108,537 (7.0) | 0.26 ± 0.63 | 0.58 ± 1.24 | 37,700 (34.7) |
| Subgroups defined by novel MMS markersd plus broad criteria (≥ 2 conditions, > $3,017 annual medication cost) | ||||
| 1+ complex medication | 9,008 (0.6) | 0.32 ± 0.74 | 0.75 ± 1.45 | 3,600 (39.9) |
| 1+ risky medication | 82,743 (5.4) | 0.24 ± 0.62 | 0.51 ± 1.17 | 27,400 (33.1) |
| 1+ costly medication | 14,609 (0.9) | 0.20± 0.55 | 0.43 ± 1.03 | 4,200 (28.6) |
| Any 1 MMS marker | 84,124 (5.5) | 0.22 ± 0.58 | 0.49 ± 1.11 | 26,200 (31.2) |
| Any 2 MMS markers | 10,389 (0.7) | 0.30 ± 0.72 | 0.60 ± 1.39 | 4,100 (39.3) |
| All 3 MMS markers | 486 (0.0) | 0.47 ± 0.97 | 0.69 ± 1.65 | 200 (47.5) |
| Subgroups defined by novel MMS markersd plus narrow criteria (≥ 3 conditions, >$3,017 annual medication cost) | ||||
| 1+ complex medication | 7,799 (0.7) | 0.35 ± 0.78 | 0.77 ± 1.50 | 3,300 (42.6) |
| 1+ risky medication | 71,605 (4.6) | 0.27 ± 0.65 | 0.53 ± 1.21 | 25,600 (35.7) |
| 1+ costly medication | 12,228 (0.8) | 0.22 ± 0.59 | 0.45 ± 1.07 | 3,900 (31.5) |
| Any 1 MMS marker | 71,535 (4.6) | 0.25 ± 0.61 | 0.51 ± 1.15 | 24,300 (34.0) |
| Any 2 MMS markers | 9,375 (0.6) | 0.33 ± 0.75 | 0.63 ± 1.43 | 3,900 (41.4) |
| All 3 MMS markers | 449 (0.0) | 0.49 ± 1.00 | 0.72 ± 1.70 | 200 (49.7) |
aData source: National sample of commercially insured continuously enrolled population aged 18-64 years for calendar year 2014.
bGaps in adherence assessed for a subset of 11 therapeutic categories using ACG software version 12.0. A gap was defined as any interval between the end of the days supply of the first prescription and the onset of a new prescription for the same medication greater than the defined grace period.
cThese eligibility criteria are defined by CMS for the Medicare program. The cost threshold is defined each year and involves the likely costs of covered Part D drugs ($3,017 for 2014).18 The chronic conditions assessed can either include any chronic diseases or specific chronic diseases as defined by the Part D plan (eg, diabetes, dyslipidemia, and end-stage renal disease). This analysis used any chronic condition.
dThis represents the novel high-risk markers developed by this project and described in this study.
ACG=Johns Hopkins Adjusted Clinical Group system; CMS = Centers for Medicare & Medicaid Services; MMS = medication management score; MTM=medication therapy management.