In this study, MTM was implemented in middle-aged and elderly MMD patients with hypertension to observe the impact of MTM on blood pressure, EQ-5D scale, average daily medication therapy cost, readmission rate, and number of DRPs.
We found that diastolic and systolic blood pressure of the intervention group in the sixth and twelfth months after discharge were significantly lower than that at the initial phase of admission (P < 0.05). Moreover, the control of diastolic and systolic blood pressure in the intervention group was significantly better than in the control group in the twelfth month after discharge (P < 0.05). During the MMD management, MTM service may have helped to control the blood pressure in patients with hypertension, which is beneficial to the treatment of hypertension in longer periods of discharge and can be regarded as one of the key tasks of pharmacists.
NCDs are the main ailments threatening health and deteriorating the quality of life. Therefore, the pharmaceutical service should also focus on improving the patients’ quality of life . In this study, after a 12-month follow-up of the two groups of patients, the EQ-5D utility value increased compared with that at the initial admission phase. However, there was no statistical difference between the two groups. From the results of this study, the MTM service was not confirmed to be better in improving the utility value than the general pharmaceutical service. These results may be because the MMD patients selected in the current study had hypertension and the symptoms of hypertension often vary from person to person; most of them are asymptomatic or not obvious. In addition, the EQ-5D scale has a large ceiling effect , so the EQ-5D scale cannot accurately reflect the health status of patients with hypertension.
Moreover, MMD patients take multiple drugs simultaneously, with serious economic burdens caused by drug costs. According to statistics, the direct economic cost to older adult patients caused by improper management of polypharmacy is as high as USD 2 billion annually . In this study, the average daily medication therapy cost for patients at the initial admission phase was as high as RMB 137.16/day. After a 12-month follow-up, the average daily medication therapy cost for the intervention group decreased from RMB 50.58 to RMB 35.43, with a maximum decrease of RMB 76.03/day. The average daily medication therapy cost for the intervention group in the first, third, sixth, and twelfth months after discharge statistically decreased compared with that at the initial phase of admission (P < 0.05). The average daily medication therapy cost for the intervention group in the twelfth month after discharge significantly decreased compared with that of the control group (P < 0.05). According to a retrospective study, during a ten-year period, for 9068 patients who received MTM service, the total expenses of the health system decreased by USD 2,913,850 . Briefly, compared with pharmacists’ general medication education and consultation, the MTM service could further reduce the economic burden on patients’ families, which could be regarded as one of the key tasks of pharmacists.
Studies have shown that patients with polypharmacy are more prone to problems such as improper medication management and adverse drug reactions, which increases hospitalization rates . In this study, the readmission rate in the intervention group in the sixth and twelfth months after discharge was less than that in the control group (P > 0.05). This may be because the follow-up time is not long enough to reflect MTM’s advantage in reducing the readmission rate.
DRPs refer to events or situations in medication therapy that have interfered or will interfere with the expected therapy results. These problems include adverse drug reactions, medication errors, unclear purpose of drug use, and inappropriate drug selection. The incidence of DRPs gradually increases with the increase in the number of drugs used by patients; 79.8% of older adult patients with polypharmacy have at least one DRP , and adding another drug will increase the DRPs by 10% . According to the studies, the incidence of DRPs in patients taking five and over ten types of drugs is 30% and 47%, respectively . Many studies have shown that DRPs may lead to a decline in patients’ quality of life, an overall increase in hospitalization and medical costs, and even an increase in readmission rate and mortality [10, 27,28,29]. After a 12-month follow-up, the number of DRPs in the two groups all decreased. Moreover, the number of DRPs solved in the intervention group in the third, sixth and twelfth months after discharge were statistically higher compared with that in the control group. Drug use in MMD patients is characterized by a wide variety of drugs, complex usage and dosage, and long-term medication, which are critical reasons for poor patient compliance. Specifically, the most common situations include forgetting to take drugs, adverse drug reactions, and thinking they do not need to take the drugs . This results in problems such as disease aggravation and deteriorating health conditions. After the MTM service had been given by Hale et al.  to the patients, the patient compliance significantly increased. Futhermore, Zhao et al.  confirmed that MTM services were efficacious in resolving DRPs and improving adverse drug reactions. They are consistent with our conclusion. Compared with general pharmaceutical services, MTM service could effectively solve these DRPs, reduce their adverse reactions, improve patient compliance and the accuracy of drug use in patients. This, in turn, would improve the patients’ quality of life, consistent with the results in the U.S. “Fairview Health Services” project .
It has been over ten years since MTM was proposed and has become a mature pharmaceutical care covered by Medicare in the United States. The effect of its implementation has also been tested in practice and confirmed by relevant research, and the effect is very significant in clinical, economic, and humanistic aspects.
The new “patient-centered” pharmaceutical care service model—MTM service—enables pharmacists with professional skills to help patients identify and solve problems in medication. Also, clinical pharmacists can be more quickly and better integrated into the clinical treatment team, which reflects the value of pharmacists and contributes to the development of hospital pharmacy in China [34, 35].
The MTM model will be established for MMD in patients with hypertension to help them understand their therapeutic drugs, reduce DRPs, improve patient compliance, reduce their financial burden, and actively convey health consciousness and a healthy lifestyle to patients. Meanwhile, pharmacists will be assisted in improving their pharmaceutical service and MMD management capability, strengthening their communication with patients, improving their service enthusiasm, and reflecting on their professional value.
In the future, a drug management model for chronic disease patients should be explored through medical associations, led by clinical pharmacists and participated in by pharmacists in community pharmacies, to obtain better service effects.
Strengths and limitations
Strengths: The MTM mode was established for MMD inpatients. The evaluation indexes include clinical indicators, economic outcomes, human outcomes, and the number of DRPs. The evaluation is relatively comprehensive. Meanwhile, the pharmacists will be assisted in improving their pharmaceutical service and MMD management capability, strengthening their communication with patients, improving their service enthusiasm, and reflecting on their professional value.
Limitations: Clinical pharmacists delivered the intervention and assessed the outcomes, increasing the risk of biased assessment. However, the outcome was assessed using an objective measurement tool, which may have minimized the potential effects of this bias on the outcome. In the future, using third-party personnel to measure the clinical outcomes may help mitigate bias. Additionally, the overall drop-out rate in this study was 15.8%, which is slightly higher than that observed in previous pharmacy studies of patients. Due to the limited pharmacists in medical institutions, there are not enough pharmacists capable of undertaking pharmaceutical care. Older adults do not fully recognize MTMs, and long-term follow-up leads to a slightly higher rate of loss to follow-up. In the future, we will actively cooperate with community pharmacists to provide more comprehensive and long-term services to MMD patients. Finally, analyses were conducted and it was determined that the group lost to follow-up was not statistically associated with the group successfully followed up. While these analyses reduced selection bias to some extent, they may inevitably lead to biased results, for example, data on people who were missed due to deteriorating health status may have had some impact on the outcome of the intervention group. Therefore, we need larger sample sizes and better designs in the future.