Unclear if medical therapy management improves health outcomes

1. There is insufficient evidence to make conclusions on the effects of medical therapy management (MTM) programs on mortality, morbidity and adverse drug events.

2. There is low-strength evidence for MTM intervention improving medication adherence, health care expenditures and risk of hospitalizations of patients with diabetes and heart failure.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Medications, while foundational to patient care, also provide an opportunity for adverse events. They may be wrongly prescribed, patients may be non-adherent or they may be inadequately dosed. Medical therapy management (MTM) programs provide a strategy to deliver services to patients and clinicians to help decrease the occurrence of these adverse events. However, the efficacy of these programs on health care outcomes is unknown. This systematic review aimed to assess the risks and benefits of outpatient-based MTM programs when compared to usual care in patients with chronic illnesses. Particularly, this study looked at medication-related problems, morbidity, mortality, quality of life, health care use, costs and harms.

There was insufficient evidence to draw conclusions on a majority of the a priori determined health care outcomes. The interventions did show some improvement in medication appropriateness, medical adherence, health plan expenditures on medications and risk of hospitalizations in patients with diabetes and heart failure, but did not show improvement in measures of quality of life outcomes, and patent satisfaction. However, due to high heterogeneity among interventions and study populations and medium to high risk of bias among all studies, the evidence strength for these results is low. Strengths of this study include being a thorough systematic review on the evidence of MTM program use, as well as examining a large number of patient centered outcomes. However, decreased study quality and intervention and population variability resulted in an inability to pool results and thus limits the applicability of this review’s findings.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Medication therapy management: its relationship to patient counselling, disease management, and pharmaceutical care

In-Depth [systematic review and meta-analysis]: This systematic review and meta analysis examined all MTM-related randomized controlled trials (RCTs), nonrandomized clinical trials (NRCT), cohort studies and case-control studies in MEDLINE, Cochrane Library and the International Pharmaceutical Abstracts database from inception to January 2014. Quality of studies was assessed and studies were rated as low, medium, high, or unclear risk of bias. Of 2,516 articles found, 61 articles (representing 44 studies) met inclusion criteria: 21 RCTs, 4 NRCTs, and 19 cohort studies. Six of these studies were included in the meta-analyses. The majority of these studies were rated as having medium or high risk of bias. Results were unable to be pooled due to this high level of bias and heterogeneity.

There was a 4.6% improvement in medication adherence, and improvement in medication appropriateness (4.9 vs 0.9 points on a medication appropriateness index, p<0.001). For patients with diabetes and heart failure there was a decrease in risk of hospitalizations (OR 0.9, 95%CI 0.91-0.93 and HR 0.55, 95%CI 0.39-0.77, respectively). The meta-analysis included 4 low bias studies and showed non-significant impact of MTM programs on overall mean number of outpatient visits and overall mean number of hospitalizations.

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