A study by a team consisting mostly of Kaiser clinical pharmacists published in Pharmacotherapy finds that a very inexpensive pharmacist consult for cardiac patients reduces the cardiac death rate by more than 80% and — even though it’s a cardiac-specific drug regimen consult — also reduces the non-cardiac death rate by more than 95% vs. what Kaiser’s doctors achieved with usual care. Plus, even though it increases drug use, it 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, in general, but especially from non-cardiac causes…and that Kaiser is losing huge amounts of money if they don’t do this.
However, the study’s conclusions violate every “rule of plausibility” and are invalid. This study, unless its invalidity becomes more widely recognized, could also be used to justify expanded reimbursements for clinical pharmacist consults. Clinical pharmacists may or may not deserve expanded reimbursement, but justification for that reimbursement cannot be made based on studies like this one.
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 somehow spent 20% less on drug therapy than the control group had spent, and saw the doctor 12% less.
Third, these two very sick, frequently hospitalized groups 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, vs. almost a fifth for the average adult.
Finally, Kaiser’s bottom line benefited immensely, because the return-on-investment (ROI) 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 save 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 unprecedented that $56 can be earned for every dollar spent, not to mention the lives that could be saved.
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 (1) why drug use was lower in the study group getting “aggressive drug therapy” than in the control group; (2) why cardiac patients cost Kaiser $93,800/year instead of $20,000-$30,000 like every other health plan; and (3) 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.”
Of course the “real” answer is that Kaiser’s doctors are perfectly competent and presumably call upon pharmacist consults when they need them. Likewise, pharmacists in Kaiser’s cardiac program, no doubt perfectly competent themselves, don’t have any “special sauce” which earns a 56-to-1 ROI and without which cardiac patients are 22x more likely to die of non-cardiac causes than otherwise.
The real answer is also, as in many other cases (such as the North Carolina Medicaid posting from last month), don’t automatically believe what you read. Instead apply some common sense and plausibility tests to the findings. If people did those two things routinely, the cost savings to the health care system would be substantial.
 Thomas Delate, Kari L Olson, Jon Rasmussen, Kara Hutka, Brian Sandhoff, Roseanne Hornak and John Merenich (2010). Reduced Health Care Expenditures After Enrollment in a Collaborative Cardiac Care Service. Pharmacotherapy: Volume 30, Issue 11, pp. 1127-1135.
Al Lewis is founder and President of the Disease Management Purchasing Consortium International, Inc. DMPC is by far the leading outcomes measurement evaluator and vendor procurement broker in the field of disease management for health plans, and increasingly for self-insured employers and state programs. Almost every disease management program procured by DMPC has won awards for disease management excellence.