The role of integrated medical and prescription drug plans in addressing racial and ethnic disparities in medication adherence

Racial Inequities, Multiple Sclerosis, and Implementation of a Novel Treatment Algorithm at the Health System Level

BACKGROUND AND OBJECTIVES

Advances in multiple sclerosis (MS) have not translated into equitable improvements in MS treatment or outcomes among minoritized people. Our objective was to determine whether a health system intervention designed to increase use of highly efficacious treatments (HETs) was implemented equitably and led to similar improvements in MS outcomes across racial and ethnic groups.

METHODS

We designed and implemented an MS treatment algorithm that aligns a person's risk of disability with appropriately efficacious disease-modifying therapies (DMTs) and incorporates social determinants of health and patient preferences that can adversely affect adherence but does not include race or ethnicity. We used Kaiser Permanente Southern California's electronic health record to conduct a trend study of DMT utilization and annual relapse rates (ARRs) stratified by race and ethnicity before (2009-2011) and during (2012-2023) implementation of the treatment algorithm.

RESULTS

We identified 6,119 (978 Black, 1741 Hispanic, 3,400 White) DMT-treated patients with MS (mean age = 50.1 years, 75.4% female) during the study period. Before implementation, Hispanic DMT-treated patients had significantly higher ARRs per 1,000 person-years (PY) (245.1, 95%CI 205.5-284.8) compared with White DMT-treated patients (156.3, 95%CI 137.8-174.7). Black people had higher ARRs compared with White people before and during early implementation, but this difference was significant only in 2015. Over the 12 years of implementation, the increase in HET use (primarily rituximab) among DMT-treated patients with MS was highest among Hispanic people, followed by Black and White people (89.3%, 87.4%, and 82.9% in 2023, respectively). The corresponding decline in age-adjusted and sex-adjusted ARR (linear spline regression) was greatest among Hispanic (90%, 95% CI 89%-91%), followed by White (86%, 95% CI 85%-87%) and Black (82%, 95% CI 80%-84%) DMT-treated patients between 2011 and 2023. By 2023, no clinically significant difference in ARR between groups remained (35.5, 19.0, and 18.1 per 1,000 PY for Hispanic, Black, and White people, respectively).

DISCUSSION

Implementation of our novel health system intervention led to marked and equitable improvements in HET use and relapse rate reduction among Hispanic, Black, and White DMT-treated patients with MS. This indicates that implementing an algorithmic approach to increase HET use, particularly an affordable one, rituximab, can reduce racial and ethnic disparities in MS outcomes.

Barriers and facilitators for improving oral anticoagulant medication adherence in lower extremity deep venous thrombosis patients after spinal surgery: A qualitative study using the COM-B model

BACKGROUND

Deep venous thrombosis (DVT) of the lower extremity causes a major disease burden globally. Currently, oral anticoagulant therapy is used as the first-line treatment of DVT, however, medication non-adherence remains a serious problem for postoperative spinal surgery patients whose DVT incidence is at a high level.

AIMS

To explore barriers and facilitators affecting patient oral anticoagulant medication adherence, based on guidance using the COM-B model.

METHODS

This study was a qualitative study using a descriptive research design with in-depth and semi-structured interviews. Data were analyzed adopting traditional content analysis methods.

RESULTS

Based on the COM-B theoretical model, we identified 9 barriers and facilitators from capability, opportunity, and motivation domains.

CONCLUSIONS

Patients were confronted with barriers from capability, opportunity, and motivation domains, which were not isolated but interrelated. Future interventions should incorporate facilitators and barriers to address medication adherence issue with a holistic approach at multiple levels.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

Racial and social inequities in medication use: A review of articles responding to the Journal of Managed Care + Specialty Pharmacy's Call to Action

This article provides a summary of Viewpoint and Research articles responding to the 2020 Journal of Managed Care + Specialty Pharmacy Call to Action to address racial and social inequities in medication use. We find great heterogeneity in terms of topic, clinical condition examined, and health disparity addressed. Common recommendations across Viewpoint articles include the need to increase racial and ethnic diversity in clinical trial participants, the need to address drug affordability and health insurance literacy, and the need to incentivize providers and plans to participate in diversity initiatives, such as the better capture of information on social determinants of health (SDOH) in claims data to be able to address SDOH needs. Across research articles, we also find a large range of approaches and study designs, spanning from randomized controlled trials to surveys to observational studies. These articles identify disparities in which minoritized beneficiaries are shown to be less likely to receive medications and vaccines, as well as less likely to be adherent to medications, across a variety of conditions. Finally, we discuss Healthy People 2030 as a potential framework for future health disparity researchers.

Immunomodulator adherence in multiple myeloma patients with lower socioeconomic status: a retrospective study

OBJECTIVE

Poor adherence to oral chemotherapy adversely impacts clinical outcomes and escalates overall healthcare costs. Despite barriers to medication adherence, a significant gap remains in assessing adherence to oral chemotherapy among multiple myeloma (MM) patients with lower socioeconomic status. Hence, our study aims to evaluate immunomodulator adherence in MM patients at a county hospital, primarily serving underrepresented and indigent individuals with low socioeconomic status across the greater Houston area.

METHODS

Inclusion criteria composed of patients diagnosed with MM, aged at least 18 years, and treated with lenalidomide or pomalidomide-two widely used immunomodulators-for a minimum of 2 months or having two or more records of dispensation between May 2019 and May 2021. Adherence was gauged using an adjusted version of the medication possession ratio (MPR).

RESULTS

Sixty-two patients were enrolled, yielding a mean MPR value of 88% (SD, ± 18.9). Of these, 43 patients (69.3%) demonstrated adherence with an MPR of ≥ 0.90. A significant difference was found in treatment duration between the adherent (mean 8.8 months; SD, ± 7.2) and non-adherent (mean 13.4 months; SD, ± 7.9) groups (p = 0.027). Notably, race/ethnicity demonstrated a significant difference (p = 0.048), driven by disparities in African American and Hispanic representation across adherence levels.

CONCLUSION

In summary, our findings highlight race and treatment duration to be predictors of immunomodulator adherence among MM patients with lower socioeconomic status. Further research is imperative to devise and test innovative interventions aimed at enhancing medication adherence, thereby contributing to improved survival and healthcare quality in this population.

A primer on managed care pharmacy

This primer defines the practice of managed care pharmacy and introduces key competencies of managed care pharmacy organizations, including pharmacy benefit design and implementation, formulary and medication utilization management, clinical program development and implementation, quality and safety program management, and promotion of affordability.

Racial and Ethnic Disparities and Prevalence in Prescription Drug Misuse, Illicit Drug Use, and Combination of Both Behaviors in the United States

This study examines racial and ethnic disparities and prevalence in prescription drug misuse, illicit drug use, and the combination of both behaviors in the United States. Using five waves of the National Survey on Drug Use and Health (NSDUH, 2015-2019; n = 276,884), a multinomial logistic regression model estimated the outcomes of prescription drug misuse, illicit drug use, and the combination of both behaviors. Participants' age was considered as an interaction effect. Approximately 5.4%, 2.9%, and 2.5% misused prescription drug, used illicit drug, or had both behaviors, respectively. Compared with White participants, Black (AOR = 0.69, 99.9 CI: 0.61, 0.79) and Asian (AOR = 0.60, 99.9% CI: 0.42, 0.87) participants had significantly lower odds of reporting prescription drug misuse. Individuals who were classified as others had higher odds of reporting illicit drug use (AOR = 1.31; 99.9% CI: 1.05, 1.64), compared with White participants. Black (AOR = 0.40, 99.9% CI: 0.29, 0.56) and Hispanic (AOR = 0.71, 99.9% CI: 0.55, 0.91) participants were significantly less likely to have both prescription drug misuse and illicit drug use behaviors. Interaction analysis showed that Black participants between 18 and 49 years old were less likely to participate in prescription drug misuse. However, Black participants who were 50 years of age or above were more likely to engage in illicit drug use and the combination of both prescription drug misuse and illicit drug use (all p < 0.001). Hispanic adult participants between 18 and 49 years old were more likely to engage in illicit drug use. Successful intervention and cessation programs may consider the cultural and age disparities among different racial and ethnic groups.