Retrospective Review of Exceptions for Angiotensin-Converting Enzyme Inhibitor or Angiotensin II Receptor Blocker Recommendations for a Diabetic Medicare Population.

Abstract

Renin-angiotensin system (RAS) antagonists are recommended for people with diabetes and hypertension or with elevated urinary albumin excretion. RAS antagonists are beneficial for some, yet clinically inappropriate for others. The percentage of patients for whom RASs are clinically inappropriate has not been compared across health plans. To (a) identify reasons why RAS therapy was not recommended and (b) compare exception percentages between health plans. This retrospective, cross-sectional analysis included Medicare Part D beneficiaries with diabetes, enrolled in health plans (n = 96) participating in a university-based medication therapy management (MTM) program between January 1 and December 31, 2013. The MTM program evaluated patient eligibility for RAS therapy via (1) a clinically derived software system assessing demographics and medication history, and (2) telepharmacist-delivered medication reviews. The MTM program database calculated the number of patients with diabetes and percentage of RAS therapy exceptions. An average of 55% of patients with diabetes qualified for MTM (range: 19%-88%). Of the 218,589 eligible, 94,359 had 1 or more reasons contraindicating RAS therapy (exception). For an average of 29% of patients, it was inappropriate to recommend the addition of an RAS antagonist; the overall exception rate ranged from 3% to 83%, suggesting a wide variation of exception rates for all health plans. A substantial difference existed across health plans where RAS therapy was considered clinically inappropriate to recommend for patients with diabetes. Future research must examine variations in therapy exceptions to understand the effect of encouraging broad-population RAS antagonist use. SinfoníaRx provided funding for this project. Wild, Boesen, and Werner are employed by SinfoniaRx, which provided grant funding to the University of Arizona College of Pharmacy for the conduct of this study. This project was presented at the AMCP 27th Annual Meeting and Expo; April 8-10, 2015; San Diego, CA.