评估MTM质量指标制定的证据：一项范围综述Assessing Evidence for MTM Quality Measure Development: A Scoping Review | AJMC

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医疗费用：两项研究检查了医疗费用结局。[22,39] 与其他结局类似，研究缺乏特异性，干预组对MTM资格的要求相似但不完全相同。

所有进行直接性评估的研究都限制了下结论的能力，即无法得出有直接的证据体支持特定干预对结局的影响，原因要么是报告的信息存在空白，要么是人群、干预措施和结局之间存在差异。

一致性评估

两项研究评估了阿片类药物和苯二氮卓类药物的同时使用，均发现干预组的结果有利。[24,37] 两项研究检查了MTM干预对处方费用的影响，结果不一致。[22,39] 一项研究发现处方费用结果有利[22]，而另一项发现干预组和比较组在处方费用方面无差异。[39] 在评估药物依从性作为个体结局的4项研究中，[22,24,41,42] 没有两项研究对同一药物类别发现相似结果。最后，两项研究检查了医疗费用结局，发现干预组的结果有利。[22,39]

精确性评估

鉴于在偏倚、直接性和一致性评估中发现的显著局限性，未进行精确性评估。

总体而言，证据基础存在显著空白和变异。每个结局最多有两项研究报告了一致的结果，但每个结局的两项研究中至少有一项没有充分报告干预的细节。只有一项研究包含了足够的MTM干预描述以复制实施（例如，交付方式、MTM干预、对照组、结局和MTM资格标准）。[39] 因此，描述MTM服务对结局影响的证据体的确定性被评为低，表明证据有限。

讨论

本项MTM证据范围综述的主要发现是：（1）基于研究设计，证据存在高水平的偏倚；（2）研究的人群和干预措施各不相同，导致结果不一致；（3）研究中存在研究细节、药物相关需求及其各自结局报告不一致的问题。由于这些局限性，没有足够的证据支持制定新的MTM质量指标的合理性。

偏倚出现是因为许多研究没有采用对照组，或者没有报告干预组和对照组之间平衡的基线特征，使得难以断言MTM服务影响了所研究的结局。

相关地，拒绝MTM服务并被用作对照的个体[26,33,34,36,40] 可能与接受服务的个体存在系统性差异。这些差异可能影响了患者如何看待或接受MTM服务。观察到的健康用户效应（一个已知的MTM评估局限性[21]）可能限制了关于服务对结局影响的准确结论。

本范围综述观察到人群、干预措施和评估结局的差异。尽管自2014年以来又发表了19项研究，但此处的结果与先前的发现一致[14]，即人群和干预措施的变异导致大多数结局的不一致和不精确，并认定证据基础不足以评估MTM干预对健康结局改善的影响。[14] 本综述更新了对证据的评估，并将先前综述的范围限制为仅关注D部分MTM项目。

观察到的证据的直接性不支持关于D部分MTM服务与结局之间关系的结论。人群中的一些不一致源于CMS对D部分项目的变更。此外，计划发起人能够应用超出CMS要求的额外目标标准，这造成了研究人群的进一步变异。此外，提供和记录MTM服务的过程未使用标准化方法。[14] 这进一步复杂化了评估MTM服务对结局影响的能力，并导致服务和计划发起人层面的变异。未来需要同质性研究来加强证据，并建立具有一致目标人群、干预措施和结局的直接证据。

除了优先进行严谨的研究外，还需要采取若干行动来实现新的质量指标。[9] MTM利益相关者应推广MTM的护理提供标准。为了支持MTM干预的一致报告并加强数据收集和分析，MTM利益相关者应推广使用标准化健康信息技术来记录MTM服务，包括报告既解决药物相关需求又解决MTP的MTM干预措施。[9] PQA提供了两种用于交付和报告MTM服务的工具：MTP类别框架和药物治疗问题解决监测指标。这些努力将改善服务交付和文档记录，并使数据能够培育出高质量证据，所有这些都可以推动指标制定。

局限性

本综述是更大努力的一部分，旨在了解与D部分MTM相关的文献格局，这可能限制了对支持更广泛药物管理服务证据的概括性。

结论

本范围综述的结果表明，存在一些描述MTM服务与某些结局之间关联的证据，但整体证据体不足以支持为D部分MTM项目制定新的质量指标的建议。这一结论不应削弱药师提供的护理或药物管理服务的价值或证据，而是支持一个新的D部分MTM项目质量结局指标为时过早的观点。需要进行额外研究，以一致地报告干预细节并减轻偏倚风险、间接性、不精确性和不一致性，从而评估MTM服务对结局的影响。

致谢

作者感谢Dr Nicole Brandt对本项目的贡献。

作者单位：药品质量联盟（JMB, CEV, MC-B），弗吉尼亚州亚历山大市；马里兰大学药学院（CEC），马里兰州巴尔的摩市。

资金来源：无。

作者披露：作者报告与任何实体没有关系或经济利益，不会构成与本文主题的利益冲突。

作者署名信息：概念与设计（JMB, CEV, MC-B）；数据获取（JMB, CEV, MC-B）；数据分析与解读（CEV, CEC, MC-B）；稿件起草（JMB, CEV, MC-B）；对重要知识内容的稿件关键修订（JMB, CEV, CEC, MC-B）；行政、技术或后勤支持（MC-B）；监督（MC-B）。

通讯地址：Melissa Castora-Binkley, PhD, MA, Pharmacy Quality Alliance, 5911 Kingstowne Village Pkwy, Ste 130, Alexandria, VA 22315。邮箱：mcastora-binkley@pqa.org。

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