Discussion
nonadherence, cardiometabolic disease, DM/HTN, DDIs
DISEASE PROGRESSION, DISEASE, DISEASES
In patients with chronic cardiometabolic diseases, healthcare outcomes depend upon correct diagnoses and effective treatment regimens [We conducted a RCT to determine if the test improved the recognition, diagnosis, and medication management of medication nonadherence and DDIs in patients with chronic cardiometabolic diseases. The results showed large differences between the intervention and the control groups: physicians who used the CDM test were 50.4x more likely to diagnose medication nonadherence and 26.9x more likely to diagnose DDIs compared to the control. Importantly, they also provided improved subsequent care: they were 3.3x more likely to restart the medication, the appropriate way to address nonadherence, and 15.7x more likely to stop or switch the interacting medications, the appropriate treatment for DDIs. The difference-in-difference calculations for DxTx scores, our combined measure of diagnostic and therapeutic improvement, confirmed this effect.Although the CDM test could not explicitly test for disease progression, physicians could diagnose disease progression by deduction after the CDM test excluded NA and DDIs. Even though intervention physicians were more likely to identify disease progression, there was not a significant difference when compared to control in diagnosis or treating disease progression. Should future study confirm our findings that routine use of tools, such as the CDM test, can objectively exclude non-adherence and DDI, a clinician’s ability to determine whether worsening symptoms are due to worsening clinical conditions, ineffective medications, or misdiagnosis could be improved .Interestingly, when we compared overall scores between the three case types, Afib, HF, and DM/HTN, we found no overall differences in diagnosis and treatment between each of the case types in aggregate. We interpret this finding as an indicator of the overriding challenge physicians face when caring for patients with multiple chronic conditions and accompanying polypharmacy, regardless of the specific disease, indicating the CDM Test has value across all four disease states.Overall, only 1 in 8 providers in the elective intervention group chose to order the CDM test, suggesting that even with education, a more compelling narrative on these challenges than presented in our education materials is needed to alert physicians. Notwithstanding, Int2A were significantly more likely to make the primary diagnosis (58.1% vs. 16.5%) and order the correct related treatment (48.4% vs. 22.1%), compared to Int2B. These results closely mirrored the results we saw in the first intervention, who were all given the result, and control who were not.The potential economic impact of the CDM test is compelling. Intervention ordered 0.3 fewer low-value diagnostic tests per case, leading to savings of $119. While savings realized through reduced utilization of low-value diagnostic testing is in line with the potential the CDM test costs, our analysis does not include larger direct costs; factoring in lower clinical, emergency, and hospital visits, the direct cost benefits would increase significantly. NA is estimated to cause 150,000 emergency room (ER) visits and over one million hospitalizations per year. DDIs, similarly, have been associated with 74,000 annual ER visits and 195,000 annual hospitalizations [Our findings have important implications for patients [While we made a careful effort to present cases of chronic cardiometabolic conditions commonly encountered in primary care, the nine cases used in this study could not cover all possible presentations of medication adherence and DDIs. The CDM test does not test for every drug combination; and major drug groups used by these patients were not tested for, such as, parenteral medications (including insulin), but the test incorporates a significant number of commonly encountered prescription and non-prescription substances capable of contributing to pharmacokinetic or pharmacodynamic interactions when taken with prescription medications used to treat cardiometabolic disease. This study also did not collect patient-level data, and although CPV simulations have been validated against actual practice in numerous studies, future research can address this limitation [