New Kaiser Study: Doctors Need Pharmacist Consults to Keep Their Cardiac Patients Alive

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A study by Kaiser clinical pharmacists published in this month's "Pharmacotherapy" finds that a very inexpensive pharmacist consult for cardiac patients reduces the cardiac death rate by 8x and -- even though it's a cardiac drug regimen consult -- also reduces the non-cardiac death rate by 22x vs. what Kaiser's doctors achieved with usual care, and earns a 56:1 ROI while reducing drug costs. The implication: Kaiser's doctors need Kaiser's pharmacists to prevent their cardiac patients from dying. However, the study's conclusions violate every "rule of plausibility" and are almost certainly invalid. This study, unless more critically analyzed, could also be used to justify expanded reimbursements for clinical pharmacist consults.

This is a perfect example of researchers ignoring highly implausible findings either because they didn’t notice them, or they hope readers don’t notice them.

If accurate, a study by a team of authors mostly comprised of clinical pharmacists associated with Kaiser Permanente Colorado leads to some troubling conclusions for Kaiser.

The matched-control study, published in the November issue of the peer-reviewed journal Pharmacotherapy, comes at a time when clinical pharmacists are lobbying for more direct reimbursement of pharmacy consults..

Quite a number of findings deserve mention. First, not getting the $1/patient-day of clinical pharmacist support given to the study group had apparently cost 30% of the retrospective control group patients their lives, vs. 3% of the intervention group.

Second, even though the clinical pharmacists achieved this dramatic reduction in the death rate through “early use of secondary prevention therapy” and “aggressive use of secondary prevention drugs,” the study group spent 20% less on drug therapy than the retrospective control group had spent, and saw the doctor 12% less.

Third, this very sick, frequently hospitalized control group filled less than $1900/year of prescriptions on average, only slightly more than the average adult. Less than 2% of the total claims incurred by these members went to drugspend, about a tenth of the average adult.

Finally, Kaiser’s bottom line benefited immensely, because the return-on-investment exceeded 56:1. A typical ROI for disease management elsewhere is somewhere between 1:1 and 2:1. One would wonder why, if a simple $1/day intervention could keep ten times more patients alive and earn Kaiser $56 for every dollar spent, Kaiser didn’t stop the study midway through and immediately change their guidelines for future patients, and that other health plans didn’t do so immediately upon this article’s publication. It is rare that $56 can be earned for every dollar spent, not to mention the lives that could be saved.

“I doubt any of those study conclusions and implications are accurate. Kaiser’s doctors, whom I consider to be among the best in the field at adhering to guidelines, are not negligently killing their patients.    If I were one of Kaiser’s doctors, I would be quite upset about the implication that their patients who get a cardiac drug makeover from a pharmacist costing $1/day are 10x less likely to die than patients who rely on their Kaiser doctors for care, and 22x less likely to die of non-cardiac causes,” observes Al Lewis, president of the Disease Management Purchasing Consortium (http://www.dismgmt.com).

“It is certainly possible that there is some incremental value in a clinical pharmacist consult, but not enough to save $21,000 on every cardiac patient. But the greater value is to justify more reimbursement opportunities for clinical pharmacists, and to serve as a teaching tool in my new guidebook 'Outcomes Measurement for Dummies..and Smarties.' ”

'Outcomes Measurement' mathematically deconstructs this Kaiser study (along with other mathematically impossible or provably invalid savings claims made by Cigna, Mercer, North Carolina Medicaid, Georgia Medicaid and several others) as part of demonstrating how to perform a “plausibility analysis” on published outcomes, promises, and program reporting. This 30-page report includes the “Seven Rules of Plausibility.” One of several plausibility rules that this Kaiser study violates is that an intervention cannot cause every element of resource use to decline, because people have to be getting their care from somewhere.

“Another rule of plausibility is that researchers ignore highly implausible findings only because they either didn’t notice them or hope readers don’t notice them. In this case, they didn’t explain why drug use was lower in the study group getting “aggressive drug therapy” than in the control group, why cardiac patients cost Kaiser $93,800 instead of $20,000 like every other health plan, and why the non-cardiac death rate was 22x higher in the control group even though this is a “collaborative cardiac care service” focused on cardiac pharmacotherapy. They didn’t even mention the record-shattering 56:1 ROI, let alone how it could be 28 times higher than what other successful care management programs achieve.”

About Disease Management Purchasing Consortium, Inc. (http://www.dismgmt.com )

DMPC was called the “leader in care management outcomes analysis,” according to the Health Industries Research Co.’s 9th Annual Report on the Disease Management and Wellness Industries. (http://www.hirc.com) Almost 200 people have achieved DMPC certification in Critical Outcomes Report Analysis (http://www.dismgmt.com/certs/measurement/honor-roll) , while roughly 30 payors have achieved DMPC Certification in Savings Measurement Validity. Managed Healthcare Executive has twice named DMPC president Al Lewis the “most influential” person in the disease management field. His book The Next Generation of Disease Management (http://www.aispub.com) will be entering its second edition in 2011.

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