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Statin use in Diabetic Patients: A Part D STAR Measure Pilot Program
editorial feature
A part D STAR measure pilot program
Hiva Pourarsalan, PharmD – Aetna Medicaid Donna Lynn M. Obra, PharmD – Aetna Medicaid Rodney Hendershot, RPh – Aetna Medicaid Conflicts of interest: None
This study was presented as a poster presentation at the 2017 Spring Annual Academy of Managed Care Pharmacy Meeting in Denver, Colorado
ABSTRACT
Purpose
The Centers for Medicare and Medicaid Services has proposed a new measure called Statin Use in Persons with Diabetes Measure (SUPD) that measures the use of statin in diabetic patients. This new quality measure targets diabetic patients 40 to 75 years old who are taking greater than or equal to two diabetes medications. Current American Heart Association/American College of Cardiology guidelines recommend patients who are 40 to 75 years old with diabetes should be put on a statin in order to prevent an atherosclerotic cardiac disease. Primary end point: Increase in number of statin claims in diabetic patients who are 40 to 75 years old and are on two or more diabetes medications without a statin. Secondary end point: increase in Statin Use in Patients with Diabetes (SUPD) Part D STAR measure.
One thousand nineteen (1,019) members with two or more diabetes medications who were between the age of 40 and 75 years old were identified utilizing patient safety report provided by Centers for Medicare and Medicaid Services (CMS), SUPD-Bene_Denominator report in August 2016. Members who had a paid claim for statins between July 31, 2016 and November 15, 2016 were excluded (245). Pharmacy claims were utilized to identify the prescribers treating diabetic patients without statins. Members whose prescriber’s fax numbers were not available were excluded (68). The identified members were divided into 6 groups to assess the effectiveness of different provider and member interventions. Group A included members whose prescribers received fax only, group B included members whose prescribers received fax plus provider call, group C included members whose prescribers received fax plus prescriber in- service, Group D included members whose prescribers received fax and received member letter, Group E included members whose prescribers received fax plus prescriber call and members received member letter, Group F included members whose prescribers received fax plus prescriber in-service and members received member letter. Prescriber faxes were sent on December 1, 2016. Prescriber calls were made mid to end of December. Member letters were mailed out in January. Prescriber in-services were provided mid-January to mid-February Member paid statin claims were assessed on May 3rd. All the groups were compared to group A. In addition, groups D, E, and F were compared to groups A, B and C respectively to assess the effectiveness of member letters.
Results
There was an increase in statin claims after interventions. Out of 702 members targeted, 93 members filled a statin through pharmacy benefits between 12/1/2016 and 04/25/2017 leading to a 13.2% increase in statin fill. Group E showed a significant increase in fills compared to group A (p=0.002), in addition group E statin claims were significantly increased compared to group B (p=0.005). Groups C, D and F did not show a significant increase in comparison to group A (p>0.05).In addition, the secondary end point of increase in SUPD measure cannot be calculated at this point as this score is calculated in 2019.
Conclusion
This pilot program showed an increase in the number of statin claims within the time frame allotted. Groups B, D, E showed an increase in the number of statin fills in comparison to group A. Group E (provider fax plus provider call plus member letter) showed a statistically significant increase in comparison to group A (provider fax only). Group E also showed a statistically significant increase in statin claims compared to group B (provider fax plus provider call), indicating that including member letters as an intervention can lead to an impact in statin use.
INTRODUCTION
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in diabetic patients. American Heart Association (AHA) and American College of Cardiology (ACC) have identified 4 different statin benefit groups: Clinical ASCVD, LDL ≥ 190 mg/dL, Diabetes (Type 1 or 2) + age 40 to 75 + LDL 70 to 189 mg/dL, Age 40 to 75 + ≥ 7.5% estimated 10year ASCVD risk. Of interest to this study, is the second group: Diabetics (Type 1 or 2) + age 40 to 75 + LDL 70 to 189 mg/dL. In addition, the recommendation on what type of statin to use in these diabetic patients depends on the 10-year ASCVD risk calculator. For patients who have a ≥ 7.5% estimated 10-year ASCVD risk, a high intensity statin is recommended and patient who have a < 7.5% estimated 10 year ASCVD risk or cannot tolerate high intensity statin a moderate intensity statin is recommended.
The Centers for Medicare and Medicaid Services has proposed a new STAR measure endorsed by Pharmacy Quality Alliance (PQA) called Statin Use in Persons with Diabetes Measure (SUPD) that measures the use of statin in diabetic patients. This new quality measure targets diabetic patients 40 to 75 years old who are taking greater than or equal to two diabetes medications. This measure will be added as a STAR measure in 2019. Interventions need to be made by the start of 2017 to meet the standards in 2019. Mercy Care Advantage (HMO SNP) is a coordinated care plan with a Medicare contract and a contract with the Arizona Medicaid Program that serves about 20,000 Medicare-Medicaid members as of January 2017.
METHODS
One thousand nineteen members who had two or more diabetes medications and were between the age of 40 and 75 years old were identified based on patient safety report provided by Centers for Medicare and Medicaid Services (CMS), SUPD-Bene_Denominator generated in August 2016. CVS generated program RxNavigator was utilized to get provider information and to evaluate statin claims before and after interventions. This methodology was chosen based to identify subject population based on CMS methodology.
Inclusion Criteria
Medicare members enrolled in MCA who are 40 to 75 years old and have 2 or more diabetes medication claims.
Exclusion Criteria
Members who had statin claims filled between July 31, 2016 to November 15, 2016 (245 members). In addition, members whose prescribers’ fax numbers were not available (68 members).
in Diabetic Patients continued
Intervention Groups
Members were divided based into six groups. Group A included members whose prescribers received fax only (306 members), group B included members whose prescribers received fax plus provider call (306 members), group C: members whose prescribers received fax plus prescriber in service (92 members), Group D: members whose prescribers received fax and members received member letter (153 members), Group E: members whose prescribers received fax plus prescriber call and members received member letter (153), Group F: members whose prescribers received fax plus prescriber in-service and members received member letter (46). Faxes were sent on December 1, 2016; provider calls are made mid to end of December and member letters were mailed out in January and provider in-services were performed in February. Member claims were assessed early May to assess the different intervention groups. All the different intervention groups were compared to group A to assess the effectiveness of each intervention. Of note, only half of the provider groups in groups C and E were able to get in-service. All groups were compared to group A (control group). Groups D, E, and F were compared to groups A, B and C respectively to assess the effectiveness of member letters.
Study Endpoints
Primary end point: Increase in number of statin claims in diabetic patients who are 40 to 75 years old and are on two or more diabetes medications without a statin.
Secondary end point: increase in Statin Use in Patients with Diabetes (SUPD) Part D STAR measure.
Statistical Analysis
P-values were calculated using a Two-Sample Proportion Test to test for significance between: P-values less than 0.05 were considered to be statistically significant
RESULTS
Out of 702 members, 93 members filled a statin through pharmacy benefits between 12/1/2016 and 4/25/2017, leading to an increase in number of statin claims. Table 1 displays demographics for members of all groups. Majority (over 50%) of the members were females and were over the age of 60 years old. P values were used to assess statistical significance. Group E statin claims were significantly increased post intervention in comparison to group A (p<0.05). Groups B, C, D and F did not show statistical significance change in number of claims as compared to group A. Table 2 displays the p value of differences between groups based on paid statin claims. Table 3 displays calculated P value for groups that received member letters to groups that did not receive member letters. Group E had a significant increase in number of statin claims compared to group B (p<0.05).
TABLE 1: Member baseline characteristics for different intervention groups
Characteristic Group A (Control Group) Group B Group C Group D Group E Group F
Female 56% 54% 61% 54% 62% 58%
Male 44% 46% 38% 46% 38% 42%
41-50 y/o 51-60 y/o >60 y/o 15% 15% 9% 16% 14% 11%
25% 30% 36% 25% 26% 27%
61% 55% 55% 59% 55% 62%
DISCUSSION
The total number of statin claims across all groups increased by13.2% after interventions. Group E showed a significant increase in fills compared to group A (p=0.003). Additionally, the number of statin claims in group E were significantly increased compared to group B (p=0.032). Groups B, C, D groups did not show a significant increase in comparison to group A (p>0.05). Overall, groups B and E had the highest increase in statin claims, indicating that pharmacistdriven provider calls can increase statin claims for members with diabetes. The number of statin claims did not statistically increase in groups E and F. Provider in-services were only scheduled for half of the provider groups in the allotted time frame. While there were no statistically significant increases in the number of statin claims in groups E and F in comparison to groups B and
TABLE 2: Comparison of Different groups to control group (A), P value of <0.05 indicates significance.
Groups Compared P Value
A vs B
A vs C
A vs D
A vs E
A vs F 0.277
0.132 0.936
0.002
0.12
C, Group E showed a significant increase in statin claims compared to group B, indicating that member letters can potentially make a difference in statin claims.
CONCLUSION
This pilot program served 702 of those members, causing an increase in overall statin claims for members who were 40 to 75 years old and on two diabetes medications. As indicated by the results, the statistically significant intervention was group E, combining provider faxes with provider calls and member letters. While inservices provide face to face time between the plan and providers, in-services may not be practical as only half of the provider groups were able to get scheduled for in-services in the allotted time frame.
Future quality improvement programs can utilize pharmacists to provide direct calls to provider offices to make intervention as groups B and E received the highest number of statin claims after interventions.
TABLE 3: Comparison of intervention groups that received member letters (D, E, F) to intervention groups that did not receive member letters (A, B, C).
Groups Compared P Value (Significant <0.05)
A vs D
B vs E
C vs F 0.936
0.032
0.544
REFERENCES
1. Announcement of Calender Year 2017 Medicare
Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. https://www.cms.gov/Medicare/Health-Plans/
MedicareAdvtgSpecRateStats/Downloads/
Announcement2017.pdf. Accessed Sep 20, 2016. 2. Mozafarian D, Benjamin EJ, et al. Executive Summary:
Heart disease and stroke statistics-2016 update: a report from the American Heart Association.
Circulation 2016; 133(4):447-54. 3. Stone NJ, Robinson JG, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol 2014;63:2889-934.
