Real-World Impact of a Pharmacogenomics-Enriched Comprehensive Medication Management Program

Abstract

The availability of clinical decision support systems (CDSS) and other methods for personalizing medicine now allows evaluation of their real-world impact on healthcare delivery. For example, addressing issues associated with polypharmacy in older patients using pharmacogenomics (PGx) and comprehensive medication management (CMM) is thought to hold great promise for meaningful improvements across the goals of the Quadruple Aim. However, few studies testing these tools at scale, using relevant system-wide metrics, and under real-world conditions, have been published to date. Here, we document a reduction of ~$7000 per patient in direct medical charges (a total of $37 million over 5288 enrollees compared to 22,357 non-enrolled) in Medicare Advantage patients (≥65 years) receiving benefits through a state retirement system over the first 32 months of a voluntary PGx-enriched CMM program. We also observe a positive shift in healthcare resource utilization (HRU) away from acute care services and toward more sustainable and cost-effective primary care options. Together with improvements in medication risk assessment, patient/provider communication via pharmacist-mediated medication action plans (MAP), and the sustained positive trends in HRU, we suggest these results validate the use of a CDSS to unify PGx and CMM to optimize care for this and similar patient populations.

Keywords: adverse drug reactions; clinical decision support systems; comprehensive medication management; cost analysis; health resources; personalized medicine; pharmacogenomics; polypharmacy; population health; treatment outcome.

Figure 1

Program workflow for the comprehensive clinical decision support system (CDSS; GeneDose LIVE™, Coriell Life Sciences, Philadelphia, PA, USA) including pharmacogenomics-enriched comprehensive medication management (PGx + CMM). The CDSS enabled a wide variety of essential activities supporting the Quadruple Aim including member engagement and education, comprehensive pharmacogenetic testing, and pharmacist review. Moreover, the CDSS facilitated both the unification of PGx with CMM and the development of pharmacist-authored medication action plans (MAPs) that were observed to drive positive changes in economics and healthcare resource utilization. Abbreviations: PGx, pharmacogenomics; CMM, comprehensive medication management.

Figure 2

Study population definitions and inclusion/exclusion criteria. Invitations for the PGx + CMM program were sent to all active TRS members. Following minimal exclusions (age, continuous medical insurance coverage, and MAP availability), data from a total of 27,000 members were used in economic and clinical evaluations of program impact. Of these, 5288 individuals voluntarily participated in the program and were defined as the intervention group. Data from the remaining 22,357 individuals were used as a contemporaneous comparison (i.e., “control”) group in analyses of economic impact. The clinical evaluation included 4716 members of the intervention group who consented to be included in this research.

Figure 3

Yearly average charges to plan per patient per month (PMPM) for the identified intervention and control groups. In the 12 calendar months pre-program (2017), the intervention group (n = 5288) was associated with average medical insurance charges of $233.17 PMPM more than the control group (n = 22,357). During the first 32 months of the PGx + CMM program, the cost curve for the intervention group appears to flatten. In this same 32 month period, the intervention group showed a significant decrease of $218.34 PMPM compared to the control group, whose costs continued to increase linearly.

Figure 4

Savings charted as monthly differences (bars) from pre-program baseline and cumulative reduction (line) in direct medical charges in the identified intervention group compared to the identified control group calculated using direct medical charges from administrative medical insurance claims data. The baseline cost is calculated as the average per patient per month (PMPM) cost over the 12 months preceding the program implementation. During the baseline period, between January 2017 and January 2018 (i.e., prior to program implementation; light grey bars), monthly differences in cost fluctuate as expected. In the 32 months post-implementation, from January 2018 to August 2020, the intervention group shows consistent positive savings in direct medical charges (dark grey bars) PMPM, generating substantial cumulative savings (dark line). In total, the PGx + CMM program has achieved a reduction of approximately $7000 per patient in direct medical charges for a total of ~$37 million over the 5288 identified participants compared to the 22,357 identified non-participants—which calculates as an average savings of $218.34 PMPM.

Figure 5

Monthly changes from baseline (average cost per patient per month over the 12 months preceding program implementation) and cumulative reduction in specific healthcare resource utilization (HRU) rates (per 1000 members) between the intervention and control groups. The impact of the PGx + CMM program on HRU was calculated using CMS place of service codes from administrative medical insurance claims data. The monthly HRU difference for the intervention group and control groups was calculated and compared to the baseline mean difference for the pre-program and 32 months following program start. The resulting differences are presented as the change from baseline for the pre-program (light grey bars) and intervention periods (dark grey bars) with cumulative amounts (dark line). The PGx + CMM program intervention group realized a consistent reduction in HRU compared to the control group in the evaluated outpatient (OP) visits, emergency department (ED) visits, and inpatient (IP) days.