Evaluating an Intervention to Improve Medication Access and Quality of Care for Underserved Populations With Chronic Conditions

慢性疾病的循证药物使用不足，部分原因是高额自付(OOP) 药物费用，占相当大的可预防的发病率和死亡率，由于慢性 疾病。这种利用不足，以及由此产生的不良健康后果，对黑人患者来说更糟糕， 拉美裔或拉丁裔，以及那些生活在农村地区的人。解决成本信息中的差距可能会减少面向对象的操作 支出和改善未充分利用的情况。有时临床医生会开出更昂贵的药物，而不是那么昂贵， 同样有效的药物之所以存在，部分原因是直到最近，它们还缺乏关于哪些药物的信息 患者必须为特定的药物付费。OOP成本信息还可以帮助患者和临床医生 与患者的偏好和目标一致的治疗选择。2019年，科罗拉多大学 医疗系统(UCHealth)在所有门诊护理站点实施实时福利工具(RTBT)， 向临床医生显示患者的OOP药物成本-患者在药房支付的成本-在 电子健康记录。医疗保险政策支持RTBT，并将增加其实施。因为成本- 相关药物使用不足在种族/少数民族和农村人口中很严重，RTBT具有 有可能在这些人群中增加符合指南的护理并减少差距。另一方面 另一方面，在患有慢性病的黑人、西班牙裔、 拉丁裔，或农村地区，因为接受护理的地方不同(例如远程医疗)、保健知识和 语言，文化认同和规范，侵蚀信任的医疗系统行为，或人际关系和 医疗保健系统中的结构性种族主义。该项目将重点关注哮喘、房颤、 糖尿病，或抑郁症--常见的慢性疾病，临床上既有昂贵的，也有低成本的 有效的药物-并衡量(1)黑人、西班牙裔或拉丁裔患者或居住在 以及(2)这些结果与其他患有相同慢性病的患者相比有何不同。 我们将使用唯一的UCHealth数据将临床用药订单、药房索赔、患者数据(包括 种族、民族、其他人口统计和健康状况)，以及RTBT数据，以评估RTBT使用和 RTBT是否与患者第一次服药有关。我们将使用科罗拉多州的所有付款人索赔 数据和差异性设计来衡量RTBT对药物使用的影响 根据国家基于证据的建议和不良的健康结果。我们将通过 访谈和焦点小组是否以及如何影响RTBT体验，是否与患者偏好一致 在他们的临床接触中，以及与积极和消极经历相关的因素。这个项目将 提供证据证明RTBT对黑人、西班牙裔、拉丁裔、 和农村慢性病患者和健康差距问题，以及实施战略 最大限度地发挥影响力。

Underuse of evidence-based medications for chronic disease, driven in part by high out-of-pocket (OOP) medication costs, accounts for substantial preventable morbidity and mortality due to exacerbation of chronic illnesses. This underuse, and the resultant adverse health outcomes, are worse for patients who are Black, Hispanic, or Latino, and those who live in rural areas. Addressing gaps in cost information may reduce OOP spending and improve underuse. Sometimes clinicians prescribe more expensive agents when less costly, equally effective medications exist, in part because, until recently, they lacked information regarding what patients must pay for a particular drug. OOP cost information could also help patients and clinicians make treatment choices that are consistent with patient preferences and goals. In 2019, the University of Colorado Health System (UCHealth) implemented in all ambulatory care sites a Real-Time Benefit Tool (RTBT) that shows clinicians a patient’s OOP medication costs—the cost the patient would pay at a pharmacy—in the Electronic Health Record. Medicare policy supports RTBTs and will increase its implementation. Because cost- related medication underuse is significant among racial/ethnic minority and rural populations, a RTBT has the potential to increase guideline-concordant care in these populations and decrease disparities. On the other hand, use of RTBT may be less frequent among populations with chronic conditions who are Black, Hispanic, Latino, or in rural areas due to differences in where care is received (e.g. telemedicine), health literacy and language, cultural identity and norms, medical system behaviors that erode trust, or interpersonal and structural racism within the health care system. The project will focus on patients with asthma, atrial fibrillation, diabetes, or depression—common chronic conditions for which there are both costly and low-cost clinically effective drugs—and measure (1) outcomes among patients who are Black, Hispanic, or Latino, or who live in rural areas and (2) how these outcomes differ compared with other patients with the same chronic conditions. We will use unique UCHealth data linking clinical medication orders, pharmacy claims, patient data (including race, ethnicity, other demographics, and health status), and RTBT data to assess variation in RTBT use and whether the RTBT is associated with patients’ first medication fills. We will use the Colorado All-Payer Claims data and a difference-in-difference design to measure the impact of the RTBT on use of medications consistent with national evidence-based recommendations and on poor health outcomes. We will characterize via interviews and focus groups whether and how RTBT affects experiences, is consistent with patient preferences in their clinical encounters, and the factors associated with positive and negative experiences. This project will produce evidence on the policy impact of an RTBT on access and quality of care for Black, Hispanic, Latino, and rural patients with chronic conditions and on health disparities, and on implementation strategies to maximize impact.