Adherence to abemaciclib in patients receiving antidiarrheal medicine

e13016

Background: According to the National Cancer Institute, breast cancer is the most common form of cancer in the United States. Nearly 75% of patients with breast cancer have tumors that are hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative. In 2017, the U.S. Food and Drug Administration (FDA) approved abemaciclib to treat adult patients who have HR+ and HER2- advanced or metastatic breast cancer. While the adverse events associated with abemaciclib have been well documented in clinical trials, it is unknown if adverse events, specifically diarrhea, impact adherence. The purpose of this study is to determine whether adherence to abemaciclib differs for patients who receive loperamide in welcome kits versus those who do not receive loperamide in welcome kits. Methods: This is a retrospective study of patients throughout the United States with HR+, HER2- breast cancer who received abemaciclib from a large specialty pharmacy from July 1, 2018 to December 31, 2019. Patients who received welcome kits (each welcome kit contains three boxes, each box contains ten 2mg tablets of loperamide) served as the intervention group; patients who did not receive welcome kits served as the standard of care group. Baseline characteristics of patients in each group were compared with t-tests for continuous data and the chi square test for categorical data. Medication possession ratio (MPR), dose reduction and dose omission rates in the first three months of taking abemaciclib were compared. Results: We identified 1,180 breast cancer patients who received abemaciclib. The intervention group had 317 patients, with an average age of 60.1 y (SD = 12.0); the control group had 863 members, with an average age of 58.7 y (SD = 11.8). Baseline characteristics did not differ significantly between groups, except for geography (p<0.001), as seen in the table. There was no significant difference (p = 0.858) in mean MPR between the intervention and standard of care groups. There were no significant differences in dose reduction rates (p= 0.390) and dose omission rates (p = 0.872) within three months of starting abemaciclib. Conclusions: Our findings suggest that patients who receive loperamide in welcome kits do not have better adherence to abemaciclib therapy. In this study, both groups showed high adherence to therapy, suggesting that the standard of care group manages diarrhea just as effectively as the intervention group. A welcome kit with loperamide did not impact a patient’s adherence to abemaciclib therapy.[Table: see text]

Utilization Patterns of Oral Disease-Modifying Drugs in Commercially Insured Patients with Multiple Sclerosis

BACKGROUND

The approval of new oral disease-modifying drugs (DMDs), such as fingolimod, dimethyl fumarate (DMF), and teriflunamide, has considerably expanded treatment options for relapsing forms of multiple sclerosis (MS). However, data describing the use of these agents in routine clinical practice are limited.

OBJECTIVE

To describe time trends and identify factors associated with oral DMD treatment initiation and switching among individuals with MS.

METHODS

Using data from a large sample of commercially insured patients, we evaluated changes over time in the proportion of MS patients who initiated treatment with an oral DMD and who switched from an injectable DMD to an oral DMD between 2009 and 2014 in the United States. We evaluated predictors of oral DMD use using conditional logistic regression in 2 groups matched on calendar time: oral DMD initiators matched to injectable DMDs initiators and oral DMD switchers matched to those who switched to a second injectable DMD.

RESULTS

Our cohort included 7,576 individuals who initiated a DMD and 1,342 who switched DMDs, of which oral DMDs accounted for 6% and 39%, respectively. Oral DMD initiation and switching steadily increased from 5% to 16% and 35% to 84%, respectively, between 2011 and 2014, with DMF being the most commonly used agent. Of the potential predictors with clinical significance, a recent neurologist consultation (OR = 1.60; 95% CI = 1.20-2.15) and emergency department visit (OR = 1.43; 95% CI = 1.01-2.01) were significantly associated with oral DMD initiation. History of depression was noted to be a potential predictor of oral DMD initiation; however, the estimate for this predictor did not reach statistical significance (OR = 1.35; 95% CI = 0.99-1.84). No clinically relevant factors measured in our data were associated with switching to an oral DMD.

CONCLUSIONS

Oral DMDs were found to be routinely used as second-line treatment. However, we identified few factors predictive of oral DMD initiation or switching, which implies that their selection is driven by patient and/or physician preferences.

DISCLOSURES

This study was funded by CVS Caremark through an unrestricted research grant to Brigham and Women's Hospital. Shrank and Matlin were employees of, and shareholders in, CVS Health at the time of the study; they report no financial interests in products or services that are related to the subject of this study. Spettell is an employee of, and shareholder in, Aetna. Chitnis serves on clinical trial advisory boards for Novartis and Genzyme-Sanofi; has consulted for Bayer, Biogen Idec, Celgene, Novartis, Merck-Serono, and Genentech-Roche; and has received research support from NIH, National Multiple Sclerosis Society, Peabody Foundation, Consortium for MS Centers, Guthy Jackson Charitable Foundation, EMD-Serono, Novartis Biogen, and Verily. Desai reports receiving a research grant from Merck for unrelated work. Gagne is principal investigator of a research grant from Novartis Pharmaceuticals Corporation to the Brigham and Women's Hospital and has received grant support from Eli Lilly, all for unrelated work. He is also a consultant to Aetion and Optum. Minden reports grants from Biogen and other fees from Genentech, EMD Serano, Avanir, and Novartis, unrelated to this study. The other authors have no conflicts to report. This study was presented as a poster at the International Society for Pharmacoepidemiology 32nd Annual Meeting; August 25-28, 2016; Dublin, Ireland.

Predicting Adherence to Chronic Disease Medications in Patients with Long-term Initial Medication Fills Using Indicators of Clinical Events and Health Behaviors

BACKGROUND

Efforts at predicting long-term adherence to medications have been focused on patients filling typical month-long supplies of medication. However, prediction remains difficult for patients filling longer initial supplies, a practice that is becoming increasingly common as a method to enhance medication adherence.

OBJECTIVES

To (a) extend methods involving short-term filling behaviors and (b) develop novel variables to predict adherence in a cohort of patients receiving longer initial prescriptions.

METHODS

In this retrospective cohort study, we used claims from a large national insurer to identify patients initiating a 90-day supply of oral medications for diabetes, hypertension, and hyperlipidemia (i.e., statins). Patients were included in the cohort if they had continuous database enrollment in the 180 days before and 365 days after medication initiation. Adherence was measured in the subsequent 12 months using the proportion of days covered metric. In total, 125 demographic, clinical, and medication characteristics at baseline and in the first 30-120 days after initiation were used to predict adherence using logistic regression models. We used 10-fold cross-validation to assess predictive accuracy by discrimination (c-statistic) measures.

RESULTS

In total, 32,249 patients met the inclusion criteria, including 14,930 patients initiating statins, 12,887 patients initiating antihypertensives, and 4,432 patients initiating oral hypoglycemics. Prediction using only baseline variables was relatively poor (cross-validated c-statistic = 0.644). Including indicators of acute clinical conditions, health resource utilization, and short-term medication filling in the first 120 days greatly improved predictive ability (0.823). A model that incorporated all baseline characteristics and predictors within the first 120 days after medication initiation more accurately predicted future adherence (0.832). The best performing model that included all 125 baseline and postbaseline characteristics had strong predictive ability (0.837), suggesting the utility of measuring these novel postbaseline variables in this population.

CONCLUSIONS

We demonstrate that long-term, 12-month adherence in patients filling longer supplies of medication can be strongly predicted using a combination of clinical, health resource utilization, and medication filling characteristics before and after treatment initiation.

DISCLOSURES

This work was supported by an unrestricted grant from CVS Health to Brigham and Women's Hospital. Shrank and Matlin were employees and shareholders at CVS Health at the time of this study; they report no financial interests in products or services that are related to this subject. Spettell is an employee of, and shareholder in, Aetna. This research was previously presented at the 2016 Annual Conference of the International Society for Pharmacoepidemiology; August 25-28, 2016; Dublin, Ireland.

An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs

Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care.

Predicting 1-Year Statin Adherence Among Prevalent Users: A Retrospective Cohort Study

BACKGROUND

Attempts to predict who is at risk of future nonadherence have largely focused on predictions at the time of therapy initiation; however, these users are only a small proportion of all patients on therapy at any point in time. Methods to predict nonadherence for established medication users, which have not been previously described in the literature, would be helpful to guide efforts to enhance the use of evidence-based therapies.

OBJECTIVE

To test approaches for adherence prediction among prevalent statin users, namely the use of short-term filling behavior, investigator-specified predictors from medical and pharmacy administrative claims, and the empirical selection of potential predictors using the high-dimensional propensity score variable selection algorithm.

METHODS

Medical and prescription claims data from a large national health insurer were used to create a cohort of patients who filled statin medication prescriptions in January 2012. We defined 6 groups of adherence predictors and estimated 10 main models to predict medication adherence in the full cohort. The same was done for the population stratified based on the days supply of the index statin prescription (≤ 30 days vs. > 30 days).

RESULTS

The study cohort consisted of 93,777 individuals, 58.4% of which were adherent to statins during follow-up. The use of 3 pre-index adherence predictors alone achieved a c-statistic of 0.70. Investigator-specified and empirically selected pharmacy, medical, and demographic variables did substantially worse (0.57-0.60). The use of 3 indicators of post-index adherence achieved a higher c-statistic than the best-performing model using pre-index information (0.74 vs. 0.72). The addition of 3 pre-index adherence predictors further improved discrimination (0.78).

CONCLUSIONS

This analysis demonstrated the ability to predict adherence among medication users using filling behavior before and immediately after an index prescription fill.

DISCLOSURES

This work was supported by an unrestricted grant from CVS Health to Brigham and Women's Hospital. Shrank, Brennan, and Matlin were employees and shareholders at CVS Health at the time of this manuscript preparation; they report no financial interests in products or services that are related to the subject of the manuscript. Franklin has received consulting fees from Aetion. Chourdry has received grants from the National Heart, Lung, and Blood Institute, PhRMA Foundation, Merck, Sanofi, AstraZeneca, and MediSafe. Spettell is an employee of, and shareholder in, Aetna. The other authors have nothing to disclose. Krumme, Choudhry, Tong, and Franklin contributed to the study design, interpretation of results, and manuscript drafting. Tong prepared and analyzed the data. Isaman, Spettell, Shrank, Brennan, and Matlin provided interpretation of results and critical manuscript revisions.

Brief Report: Intensification to Triple Therapy After Treatment With Nonbiologic Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis in the United States From 2009 to 2014

OBJECTIVE

Several trials suggest that triple therapy (methotrexate, sulfasalazine, and hydroxychloroquine) and biologic disease-modifying antirheumatic drugs (DMARDs) have similar efficacy in patients with rheumatoid arthritis (RA). This study was undertaken to investigate intensification to triple therapy after initial nonbiologic prescription among patients with RA.

METHODS

The use of triple therapy among patients with RA in 2009-2014 was evaluated using US insurance claims data. Patients with a health care visit for RA and an initial nonbiologic DMARD prescription were included. Frequencies of intensification to triple therapy or a biologic DMARD and rates of intensification per 6-month time period were calculated. Using Cox regression, we evaluated whether sociodemographic, temporal, geographic, clinical, and health care utilization factors were associated with intensification to triple therapy. Among those patients whose therapy was intensified, we investigated factors associated with triple therapy use by logistic regression. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) for intensification to triple therapy in relation to various clinical and demographic factors were calculated.

RESULTS

There were 24,576 patients with a mean ± SD age of 50.3 ± 12.3 years, and 78% were female. During the study period, treatment was intensified to biologic DMARDs in 2,739 patients (11.1%) compared to 181 patients (0.7%) whose treatment was intensified to triple therapy. There was no significant change in triple therapy use across calendar years. Patients whose treatment was intensified to triple therapy were more likely to receive glucocorticoids (HR 1.91 [95% CI 1.41-2.60]) compared to patients who did not use glucocorticoids and were more likely to use nonsteroidal antiinflammatory drugs (NSAIDs) (HR 1.48, 95% CI 1.10-1.99 versus no NSAID use). Among those patients whose treatment was intensified to triple therapy or biologic DMARDs, factors significantly associated with triple therapy use included older age, US region (with the highest odds for triple therapy use in the West and lowest odds for triple therapy use in the Northeast), glucocorticoid use, and lower number of outpatient visits within 180 days of initial nonbiologic DMARD prescription.

CONCLUSION

Despite reports published during the study period suggesting equivalent efficacy of triple therapy and biologic DMARDs for RA, the use of triple therapy was infrequent and did not increase over time in this large nationwide study.

Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial

IMPORTANCE

Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.

OBJECTIVE

To compare the effect of 3 low-cost reminder devices on medication adherence.

DESIGN, SETTING, AND PARTICIPANTS

This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population.

MAIN OUTCOMES AND MEASURES

The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants.

RESULTS

Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results.

CONCLUSIONS AND RELEVANCE

Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02015806.

Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications: A Cohort Study

BACKGROUND

Despite the widespread adoption of patient-centered medical homes into primary care practice, the evidence supporting their effect on health care outcomes has come primarily from geographically localized and well-integrated health systems.

OBJECTIVE

To assess the association between medication adherence and medical homes in a national patient and provider population, given the strong ties between adherence to chronic disease medications and health care quality and spending.

DESIGN

Retrospective cohort study.

SETTING

Claims from a large national health insurer.

PATIENTS

Patients initiating therapy with common medications for chronic diseases (diabetes, hypertension, and hyperlipidemia) between 2011 and 2013.

MEASUREMENTS

Medication adherence in the 12 months after treatment initiation was compared among patients cared for by providers practicing in National Committee for Quality Assurance-recognized patient-centered medical homes and propensity score-matched control practices in the same Primary Care Service Areas. Linear mixed models were used to examine the association between medical homes and adherence.

RESULTS

Of 313 765 patients meeting study criteria, 18 611 (5.9%) received care in patient-centered medical homes. Mean rates of adherence were 64% among medical home patients and 59% among control patients. Among 4660 matched control and medical home practices, medication adherence was significantly higher in medical homes (2.2% [95% CI, 1.5% to 2.9%]). The association between medical homes and better adherence did not differ significantly by disease state (diabetes, 3.0% [CI, 1.5% to 4.6%]; hypertension, 3.2% [CI, 2.2% to 4.2%]; hyperlipidemia, 1.5% [CI, 0.6% to 2.5%]).

LIMITATION

Clinical outcomes related to medication adherence were not assessed.

CONCLUSION

Receipt of care in a patient-centered medical home is associated with better adherence, a vital measure of health care quality, among patients initiating treatment with medications for common high-cost chronic diseases.

PRIMARY FUNDING SOURCE

CVS Health.

Can purchasing information be used to predict adherence to cardiovascular medications? An analysis of linked retail pharmacy and insurance claims data

OBJECTIVE

The use of retail purchasing data may improve adherence prediction over approaches using healthcare insurance claims alone.

DESIGN

Retrospective.

SETTING AND PARTICIPANTS

A cohort of patients who received prescription medication benefits through CVS Caremark, used a CVS Pharmacy ExtraCare Health Care (ECHC) loyalty card, and initiated a statin medication in 2011.

OUTCOME

We evaluated associations between retail purchasing patterns and optimal adherence to statins in the 12 subsequent months.

RESULTS

Among 11 010 statin initiators, 43% were optimally adherent at 12 months of follow-up. Greater numbers of store visits per month and dollar amount per visit were positively associated with optimal adherence, as was making a purchase on the same day as filling a prescription (p<0.0001 for all). Models to predict adherence using retail purchase variables had low discriminative ability (C-statistic: 0.563), while models with both clinical and retail purchase variables achieved a C-statistic of 0.617.

CONCLUSIONS

While the use of retail purchases may improve the discriminative ability of claims-based approaches, these data alone appear inadequate for adherence prediction, even with the addition of more complex analytical approaches. Nevertheless, associations between retail purchasing behaviours and adherence could inform the development of quality improvement interventions.

Association among change in medical costs, level of comorbidity, and change in adherence behavior

OBJECTIVES

Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior.

STUDY DESIGN

Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries.

METHODS

Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline.

RESULTS

We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state.

CONCLUSIONS

There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

The adherence impact of a program offering specialty pharmacy services to patients using retail pharmacies

BACKGROUND

A new service model integrates the specialty pharmacy's comprehensive service with the retail pharmacy's patient contact, giving patients options for medication delivery to home, pharmacy, or doctor's office.

OBJECTIVE

Evaluate the impact of the new service model on medication adherence.

DESIGN

Retrospective cohort study

SETTINGS

One hundred fifteen CVS retail stores in Philadelphia participated in a pilot from May 2012 to October 2013, and 115 matched CVS retail stores from around the nation served as controls.

PATIENTS

All eligible patients from the intervention and control stores received specialty medications through CVS retail pharmacies prior to implementation of the new service model.

INTERVENTION

The intervention patients were transitioned from retail pharmacy service to the specialty pharmacy with delivery options. The control patients received standard retail pharmacy services.

MAIN OUTCOME MEASURES

Proportion of days covered and first fill persistence were tracked for 12 months before and after program implementation.

RESULTS

Under the new service model, 228 patients new to therapy in the post period had a 17.5% increase in the rate of obtaining a second fill as compared to matched controls. Patients on therapy in both the pre- and the post-periods had a pre-post increase of 6.6% in average adherence rates and a pre-post increase of 10.8% in optimal adherence rates as compared to 326 matched controls.

CONCLUSION

The study demonstrated significant improvement in both adherence to therapy and first-fill persistence among patients in the new service model integrating specialty pharmacy's comprehensive services with the retail pharmacy's patient contact and medication delivery choices.

Impact of a transition to more restrictive drug formulary on therapy discontinuation and medication adherence

WHAT IS KNOWN AND OBJECTIVE

There is conclusive evidence demonstrating that formulary restrictions are associated with reduced utilization and pharmacy spending of the restricted drugs. However, prior efforts to implement restrictive formularies have been associated with inconsistent rates of therapy discontinuation and mixed impacts on adherence to therapy. Also, the impact of transferring patients from an already restrictive formulary to a more aggressive model has not been previously examined. This study evaluated the impact of implementation of a more restrictive formulary on therapy disruption, adherence rates, pharmacy costs and generic utilization among patients with common chronic conditions.

METHODS

In 2014, CVS Health implemented Value Formulary (VF), a restrictive benefit design with the aim of reducing spending while preserving access to and adherence to essential therapy, was used. A retrospective cohort study was conducted to assess changes in therapy disruption rates, pharmacy costs and generic dispensing rate (GDR) (for continuers) and medication adherence (for initiators) following the implementation of VF. The study group was selected from members of three existing employer clients transitioned from standard formulary (SF) to VF on January 2014. The control population was a matched group of six employers with the same preperiod formulary structure, business unit, adherence programmes and patient out-of-pocket cost as the study group. The control group retained SF in 2014. To assess therapy disruption after VF implementation, we categorized patients by their subsequent medication use into three groups: (i) therapy stopped, (ii) therapy continued and (iii) therapy switched. Medication adherence was measured as monthly proportion of days covered (PDC). Pharmacy cost and GDR were measured per utilizer per month (PUPM). Rates of therapy disruption in study and control groups were compared using the chi-square test. Differences in monthly PDC between matched groups were evaluated using multivariate linear regression. Impact of VF on pharmacy cost and GDR was measured through segmented regression of interrupted time series data with generalized estimating equations.

RESULTS AND DISCUSSION

A transition from SF to VF influenced drug coverage for approximately 13% of members (as their medications were either no longer covered, or covered restrictively under VF). Compared to patients whose plan sponsors retained SF, the patients that transitioned to VF had a modest (1·3%) but statistically significant increase in therapy discontinuation rates. This was offset by similarly modest improvements in adherence; patients who initiated therapy under VF demonstrated a 1·5% higher adherence to medications as compared to SF patients (P < 0·001). Medication costs in the VF group were lower by $20 PUPM (P < 0·001), and GDR was greater by 4·2% (P < 0·001).

WHAT IS NEW AND CONCLUSION

Transition of patients to a more restrictive drug formulary led to modest therapy discontinuation, similarly modest improvements in medication adherence and substantial prescription drug cost savings. As healthcare payors search for ways to control the rapid rise in spending for medications without compromising quality, the Value Formulary can serve as a useful tool.

Patient Use of Email, Facebook, and Physician Websites to Communicate with Physicians: A National Online Survey of Retail Pharmacy Users

BACKGROUND

Patient-physician communication often occurs outside the clinic setting; many institutions discourage electronic communication outside of established electronic health record systems. Little empirical data are available on patient interest in electronic communication and Web-based health tools that are technically feasible but not widely available.

RESEARCH OBJECTIVE

To explore patient behavior and interest in using the Internet to contact physicians.

DESIGN

National cross-sectional online survey.

PARTICIPANTS

A sample of 4,510 CVS customers with at least one chronic condition in the household was used to target patients with chronic conditions and their caregivers. Subjects were identified from a national panel of over 100,000 retail pharmacy customers. Of those sampled, 2,252 responded (50.0 % response rate).

MAIN MEASURES

Survey measures included demographic and health information, patient use of email and Facebook to contact physicians, and patient interest in and use of Web-based tools for health.

KEY RESULTS

A total of 37 % of patients reported contacting their physicians via email within the last six months, and 18 % via Facebook. Older age was negatively associated with contacting physicians using email (OR 0.57 [95 % CI 0.41-0.78]) or Facebook (OR 0.28 [0.17-0.45]). Non-white race (OR 1.61 [1.18-2.18] and OR 1.82 [1.24-2.67]) and caregiver status (OR 1.58 [1.27-1.96] and OR 1.71 [1.31- 2.23]) were positively associated with using email and Facebook, respectively. Patients were interested in using Web-based tools to fill prescriptions, track their own health, and access health information (37-57 %), but few were currently doing so (4-8 %).

CONCLUSIONS

In this population of retail pharmacy users, there is strong interest among patients in the use of email and Facebook to communicate with their physicians. The findings highlight the gap between patient interest for online communication and what physicians may currently provide. Improving and accelerating the adoption of secure Web messaging systems is a possible solution that addresses both institutional concerns and patient demand.

Community pharmacy automatic refill program improves adherence to maintenance therapy and reduces wasted medication

OBJECTIVES

Automatic prescription refill programs are a popular means of improving medication adherence. A concern is the potential for prescription drug wastage and unnecessary healthcare spending. We evaluated the impact of an automatic refill program on patterns of medication use.

STUDY DESIGN

Retrospective propensity score matched cohort study with multivariable generalized linear modeling.

METHODS

The setting of the study was a pharmacy benefit manager administering benefits for patients of retail pharmacies. Participants included patients on medication for chronic conditions; those receiving a 30-day supply (n = 153,964) and a 90-day supply (n = 100,394) were analyzed separately. The intervention was the automatic prescription refill program. Measures included medication possession ratio (MPR) and average days excess at the time of refill. The results are reported across 11 therapeutic classes.

RESULTS

Overall, patients receiving 30-day supplies of medication in the automatic refill program had an MPR that was 3 points higher than those not in the refill program; among those receiving 90-day fills and in the refill program, the MPR was 1.4 points higher (P < .001 for both 30- and 90-day fills). The MPR was higher for members in the refill program across all therapeutic classes. Limiting our analysis to members receiving more than 365 days of medication, we found that patients who received 30-day fills and enrolled in the automatic refill program had 2.5 fewer days' oversupply than those in the control group, whereas automatic refill patients receiving 90-day supplies had 2.18 fewer days' oversupply than the controls (P < .001 for both 30- and 90-day fills).

CONCLUSIONS

For this pharmacy provider, automatic refill programs result in improved adherence without adding to medication oversupply.

Predicting adherence trajectory using initial patterns of medication filling

OBJECTIVES

To evaluate the ability of initial medication dispensings to predict long-term patterns of adherence.

STUDY DESIGN

A retrospective cohort study of statin initiators enrolled in a Medicare Part D drug plan from CVS Caremark from 2005 to 2008.

METHODS

We used group-based trajectory models to classify patients into 6 adherence trajectories based on patterns of statin filling over the year following therapy initiation. Baseline clinical characteristics and indicators of statin filling during the first 2 to 4 months following initiation were used to predict adherence trajectory in logistic regression models, separately within strata of the days' supply of the initial statin dispensing. Cross-validation was used to measure predictive accuracy of models in data not used for model estimation.

RESULTS

Among 77,703 statin initiators, prediction using baseline variables only was poor (cross-validated C statistic ≤ 0.61). When using 3 months of initial adherence to predict trajectory, prediction was greatly improved among patients with an index supply ≤30 days (0.62 ≤ C ≤ 0.91). With 4 months of initial adherence in the model, prediction was strong for all patients (C ≥ 0.72), especially for the best and worst trajectories (C = 0.90 and 0.94, respectively, in patients with an index supply ≤ 30 days; and C = 0.83 and 0.90, respectively, in patients with an index supply > 30 days).

CONCLUSIONS

Initial filling behavior strongly predicted future adherence trajectory. Predicting adherence trajectories may facilitate better targeting of interventions to patients most likely to benefit.

Association between trajectories of statin adherence and subsequent cardiovascular events

PURPOSE

Trajectory models have been shown to (1) identify groups of patients with similar patterns of medication filling behavior and (2) summarize the trajectory, the average adherence in each group over time. However, the association between adherence trajectories and clinical outcomes remains unclear. This study investigated the association between 12-month statin trajectories and subsequent cardiovascular events.

METHODS

We identified patients with insurance coverage from a large national insurer who initiated a statin during January 1, 2007 to December 31, 2010. We assessed medication adherence during the 360 days following initiation and grouped patients based on the proportion of days covered (PDC) and trajectory models. We then measured cardiovascular events during the year after adherence assessment. Cox proportional hazards models were used to evaluate the association between adherence measures and cardiovascular outcomes; strength of association was quantified by the hazard ratio, the increase in model C-statistic, and the net reclassification index (NRI).

RESULTS

Among 519 842 statin initiators, 8777 (1.7%) had a cardiovascular event during follow-up. More consistent medication use was associated with a lower likelihood of clinical events, whether adherence was measured through trajectory groups or PDC. When evaluating the prediction of future cardiovascular events by including a measure of adherence in the model, the best model reclassification was observed when adherence was measured using three or four trajectory groups (NRI = 0.189; 95% confidence interval: [0.171, 0.210]).

CONCLUSIONS

Statin adherence trajectory predicted future cardiovascular events better than measures categorizing PDC. Thus, adherence trajectories may be useful for targeting adherence interventions.

Observing versus Predicting: Initial Patterns of Filling Predict Long-Term Adherence More Accurately Than High-Dimensional Modeling Techniques

OBJECTIVE

Despite the proliferation of databases with increasingly rich patient data, prediction of medication adherence remains poor. We proposed and evaluated approaches for improved adherence prediction.

DATA SOURCES

We identified Medicare beneficiaries who received prescription drug coverage through CVS Caremark and initiated a statin.

STUDY DESIGN

A total of 643 variables were identified at baseline from prior claims and linked Census data. In addition, we identified three postbaseline predictors, indicators of adherence to statins during each of the first 3 months of follow-up. We estimated 10 models predicting subsequent adherence, using logistic regression and boosted logistic regression, a nonparametric data-mining technique. Models were also estimated within strata defined by the index days supply.

RESULTS

In 77,703 statin initiators, prediction using baseline variables only was poor with maximum cross-validated C-statistics of 0.606 and 0.577 among patients with index supply ≤30 days and >30 days, respectively. Using only indicators of initial statin adherence improved prediction accuracy substantially among patients with shorter initial dispensings (C = 0.827/0.518), and, when combined with investigator-specified variables, prediction accuracy was further improved (C = 0.842/0.596).

CONCLUSIONS

Observed adherence immediately after initiation predicted future adherence for patients whose initial dispensings were relatively short.

Cost-effectiveness of novel regimens for the treatment of hepatitis C virus

BACKGROUND

New regimens for hepatitis C virus (HCV) have shorter treatment durations and increased rates of sustained virologic response compared with existing therapies but are extremely expensive.

OBJECTIVE

To evaluate the cost-effectiveness of these treatments under different assumptions about their price and efficacy.

DESIGN

Discrete-event simulation.

DATA SOURCES

Published literature.

TARGET POPULATION

Treatment-naive patients infected with chronic HCV genotype 1, 2, or 3.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Usual care (boceprevir-ribavirin-pegylated interferon [PEG]) was compared with sofosbuvir-ribavirin-PEG and 3 PEG-free regimens: sofosbuvir-simeprevir, sofosbuvir-daclatasvir, and sofosbuvir-ledipasvir. For genotypes 2 and 3, usual care (ribavirin-PEG) was compared with sofosbuvir-ribavirin, sofosbuvir-daclatasvir, and sofosbuvir-ledipasvir-ribavirin (genotype 3 only).

OUTCOME MEASURES

Discounted costs (in 2014 U.S. dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

Assuming sofosbuvir, simeprevir, daclatasvir, and ledipasvir cost $7000, $5500, $5500, and $875 per week, respectively, sofosbuvir-ledipasvir was cost-effective for genotype 1 and cost $12 825 more per QALY than usual care. For genotype 2, sofosbuvir-ribavirin and sofosbuvir-daclatasvir cost $110 000 and $691 000 per QALY, respectively. For genotype 3, sofosbuvir-ledipasvir-ribavirin cost $73 000 per QALY, sofosbuvir-ribavirin was more costly and less effective than usual care, and sofosbuvir-daclatasvir cost more than $396 000 per QALY at assumed prices.

RESULTS OF SENSITIVITY ANALYSIS

Sofosbuvir-ledipasvir was the optimal strategy in most simulations for genotype 1 and would be cost-saving if sofosbuvir cost less than $5500. For genotype 2, sofosbuvir-ribavirin-PEG would be cost-saving if sofosbuvir cost less than $2250 per week. For genotype 3, sofosbuvir-ledipasvir-ribavirin would be cost-saving if sofosbuvir cost less than $1500 per week.

LIMITATION

Data are lacking on real-world effectiveness of new treatments and some prices.

CONCLUSION

From a societal perspective, novel treatments for HCV are cost-effective compared with usual care for genotype 1 and probably genotype 3 but not for genotype 2.

PRIMARY FUNDING SOURCE

CVS Health.

Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study

IMPORTANCE

Although many classes of oral glucose-lowering medications have been approved for use, little comparative effectiveness evidence exists to guide initial selection of therapy for diabetes mellitus.

OBJECTIVE

To determine the effect of initial oral glucose-lowering agent class on subsequent need for treatment intensification and 4 short-term adverse clinical events.

DESIGN, SETTING, AND PARTICIPANTS

This study was a retrospective cohort study of patients who were fully insured members of Aetna (a large national health insurer) who had been prescribed an oral glucose-lowering medication from July 1, 2009, through June 30, 2013. Individuals newly prescribed an oral glucose-lowering agent who filled a second prescription for a medication in the same class and with a dosage at or above the World Health Organization's defined daily dose within 90 days of the end-of-day's supply of the first prescription were studied. Individuals with interim prescriptions for other oral glucose-lowering medications were excluded.

EXPOSURES

Initiation of treatment with metformin, a sulfonylurea, a thiazolidinedione, or a dipeptidyl peptidase 4 inhibitor.

MAIN OUTCOMES AND MEASURES

Time to addition of a second oral agent or insulin, each component separately, hypoglycemia, other diabetes-related emergency department visits, and cardiovascular events.

RESULTS

A total of 15 516 patients met the inclusion criteria, of whom 8964 (57.8%) started therapy with metformin. In unadjusted analyses, use of medications other than metformin was significantly associated with an increased risk of adding a second oral agent only, insulin only, and a second agent or insulin (P < .001 for all). In propensity score and multivariable-adjusted Cox proportional hazards models, initiation of therapy with sulfonylureas (hazard ratio [HR], 1.68; 95% CI, 1.57-1.79), thiazolidinediones (HR, 1.61; 95% CI, 1.43-1.80), and dipeptidyl peptidase 4 inhibitors (HR, 1.62; 95% CI, 1.47-1.79) was associated with an increased hazard of intensification. Alternatives to metformin were not associated with a reduced risk of hypoglycemia, emergency department visits, or cardiovascular events.

CONCLUSIONS AND RELEVANCE

Despite guidelines, only 57.8% of individuals began diabetes treatment with metformin. Beginning treatment with metformin was associated with reduced subsequent treatment intensification, without differences in rates of hypoglycemia or other adverse clinical events. These findings have significant implications for quality of life and medication costs.

Patterns of initiation of oral anticoagulants in patients with atrial fibrillation- quality and cost implications

BACKGROUND

Dabigatran, rivaroxaban, and apixaban have been approved for use in patients with atrial fibrillation based upon randomized trials demonstrating their comparable or superior efficacy and safety relative to warfarin. Little is known about their adoption into clinical practice, whether utilization is consistent with the controlled trials on which their approval was based, and how their use has affected health spending for patients and insurers.

METHODS

We used medical and prescription claims data from a large insurer to identify patients with nonvalvular atrial fibrillation who were prescribed an oral anticoagulant in 2010-2013. We plotted trends in medication initiation over time, assessed corresponding insurer and patient out-of-pocket spending, and evaluated the cumulative number and cost of anticoagulants. We identified predictors of novel anticoagulant initiation using multivariable logistic models. Finally, we estimated the difference in total drug expenditures over 6 months for patients initiating warfarin versus a novel anticoagulant.

RESULTS

There were 6893 patients with atrial fibrillation that initiated an oral anticoagulant during the study period. By the end of the study period, novel anticoagulants accounted for 62% of new prescriptions and 98% of anticoagulant-related drug costs. Female sex, lower household income, and higher CHADS2, CHA2DS2-VASC, and HAS-BLED scores were significantly associated with lower odds of receiving a novel anticoagulant (P <.001 for each). Average combined patient and insurer anticoagulant spending in the first 6 months after initiation was more than $900 greater for patients initiating a novel anticoagulant.

CONCLUSIONS

This study demonstrates rapid adoption of novel anticoagulants into clinical practice, particularly among patients with lower CHADS2 and HAS-BLED scores, and high health care cost consequences. These findings provide important directions for future comparative and cost-effectiveness research.

Quality of care at retail clinics for 3 common conditions

OBJECTIVES

Evaluation of quality of care across retail clinics in a geographically diverse population has not been undertaken to date. We sought to evaluate and compare the quality of care for otitis media, pharyngitis, and urinary tract infection received in retail medical clinics in CVS pharmacies ("MinuteClinics" [MCs]), ambulatory care facilities (ACFs), and emergency departments (EDs).

METHODS

We used 14 measures constructed from RAND Corporation's Quality Assurance Tools and guidelines from the American Academy of Pediatrics, the American Academy of Family Physicians, and the Infectious Diseases Society of America. Our cohort was drawn from Aetna medical and prescription claims, 2009-2012. Members were matched on visit date, condition, and propensity score. Generalized estimating equations were used to compare quality across clinic type, overall, and by index condition.

RESULTS

We matched 75,886 episodes of care, of which 20,153 were eligible for at least 1 quality measure. MCs performed better than EDs and ACFs in 7 measures. In a multivariable model, MCs performed better than ACFs and EDs across all quality measures ([OR 0.42; 95% CI, 0.40-0.45; P < .0001; ACF vs MC] [OR 0.29; 95% CI, 0.27-0.31; P < .0001; ED vs MC]). Results for each condition were significant at P < .0001.

CONCLUSIONS

Quality of care for these conditions based on widely accepted objective measures was superior in MinuteClinics compared with ACFs and EDs.

Comparative effectiveness of generic and brand-name statins on patient outcomes: a cohort study

BACKGROUND

Statins are effective in preventing cardiovascular events, but patients do not fully adhere to them.

OBJECTIVE

To determine whether patients are more adherent to generic statins versus brand-name statins (lovastatin, pravastatin, or simvastatin) and whether greater adherence improves health outcomes.

DESIGN

Observational, propensity score-matched, new-user cohort study.

SETTING

Linked electronic data from medical and pharmacy claims.

PARTICIPANTS

Medicare beneficiaries aged 65 years or older with prescription drug coverage between 2006 and 2008.

INTERVENTION

Initiation of a generic or brand-name statin.

MEASUREMENTS

Adherence to statin therapy (measured as the proportion of days covered [PDC] up to 1 year) and a composite outcome comprising hospitalization for an acute coronary syndrome or stroke and all-cause mortality. Hazard ratios (HRs) and absolute rate differences were estimated.

RESULTS

A total of 90,111 patients who initiated a statin during the study was identified; 83,731 (93%) initiated a generic drug, and 6380 (7%) initiated a brand-name drug. The mean age of patients was 75.6 years, and most (61%) were female. The average PDC was 77% for patients in the generic group and 71% for those in the brand-name group (P<0.001). An 8% reduction in the rate of the clinical outcome was observed among patients in the generic group versus those in the brand-name group (HR, 0.92 [95% CI, 0.86 to 0.99]). The absolute difference was -1.53 events per 100 person-years (CI, -2.69 to -0.19 events per 100 person-years).

LIMITATION

Results may not be generalizable to other populations with different incomes or drug benefit structures.

CONCLUSION

Compared with those initiating brand-name statins, patients initiating generic statins were more likely to adhere and had a lower rate of a composite clinical outcome.

PRIMARY FUNDING SOURCE

Teva Pharmaceuticals.

Equity in the receipt of oseltamivir in the United States during the H1N1 pandemic

OBJECTIVES

We assessed the relationship between individual characteristics and receipt of oseltamivir (Tamiflu) in the United States during the H1N1 pandemic and other flu seasons.

METHODS

In a cohort of individuals enrolled in pharmacy benefit plans, we used a multivariate logistic regression model to measure associations between subscriber characteristics and filling a prescription for oseltamivir during 3 flu seasons (October 2006-May 2007, October 2007-May 2008, and October 2008-May 2010). In 19 states with county-level influenza rates reported, we controlled for disease burden.

RESULTS

Approximately 56 million subscribers throughout the United States were included in 1 or more study periods. During pandemic flu, beneficiaries in the highest income category had 97% greater odds of receiving oseltamivir than those in the lowest category (P < .001). After we controlled for disease burden, subscribers in the 2 highest income categories had 2.18 and 1.72 times the odds of receiving oseltamivir compared with those in the lowest category (P < .001 for both).

CONCLUSIONS

Income was a stronger predictor of oseltamivir receipt than prevalence of influenza. These findings corroborate concerns about equity of treatment in pandemics, and they call for improved approaches to distributing potentially life-saving treatments.

Time series analyses of the effect of FDA communications on use of prescription weight loss medications

OBJECTIVE

To determine the impact of FDA safety communications regarding the weight loss medications sibutramine and orlistat.

METHODS

The 2008 to 2011 pharmacy claims data from CVS Caremark were used to determine the effect of the relevant FDA warnings on (1) use of sibutramine and orlistat, (2) their rates of discontinuation, and (3) substitution to an alternate weight loss medication in the 3-month period following discontinuation.

RESULTS

The use of sibutramine, orlistat, or phentermine declined from 45 users per 100,000 Caremark enrollees in May 2008 to 24 users per 100,000 enrollees in December 2010. In the time series analyses of overall use of medications, a very small decline in the trend of use of sibutramine after the FDA communication (0.000002% per month decline after the communication; P < 0.001) was found. However, rates of discontinuation of sibutramine and orlistat were similar before and after relevant FDA communications (all P values >0.1 for both level and trend changes post-warning). Patients discontinuing sibutramine post-communication increased use of phentermine at a rate of 0.004% per month after discontinuation (P = 0.01).

CONCLUSION

From 2008 to 2010, use of prescription weight loss medications was low and declined over time. FDA communications regarding the safety of these medications had limited effect on use.

Five features of value-based insurance design plans were associated with higher rates of medication adherence

Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans.

Untangling the relationship between medication adherence and post-myocardial infarction outcomes: medication adherence and clinical outcomes

BACKGROUND

Patients who adhere to medications experience better outcomes than their nonadherent counterparts. However, these observations may be confounded by patient behaviors. The level of adherence necessary for patients to derive benefit and whether adherence to all agents is important for diseases that require multiple drugs remain unclear. This study quantifies the relationship between medication adherence and post-myocardial infarction (MI) adverse coronary events.

METHODS

This is a secondary analysis of the randomized MI FREEE trial. Patients who received full prescription coverage were classified as adherent (proportion of days covered ≥80%) or not based upon achieved adherence in the 6 months after randomization. First major vascular event or revascularization rates were compared using multivariable Cox models adjusting for comorbidity and health-seeking behavior.

RESULTS

Compared with patients randomized to usual care, full coverage patients adherent to statin, β-blocker, or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were significantly less likely to experience the study's primary outcome (hazard ratio [HR] range 0.64-0.81). In contrast, nonadherent patients derived no benefit (HR range 0.98-1.04, P ≤ .01 for the difference in HRs between adherent and nonadherent patients). Partially adherent patients had no reduction in clinical outcomes for any of the drugs evaluated, although their achieved adherence was higher than that among controls.

CONCLUSION

Achieving high levels of adherence to each and all guideline-recommended post-MI secondary prevention medication is associated with improved event-free survival. Lower levels of adherence appear less protective.

Cost-effectiveness of oral anticoagulants for treatment of atrial fibrillation

BACKGROUND

New anticoagulants may improve health outcomes in patients with atrial fibrillation, but it is unclear whether their use is cost-effective.

METHODS AND RESULTS

A Markov state transition was created to compare 4 therapies: dabigatran 150 mg BID, apixaban 5 mg BID, rivaroxaban 20 mg QD, and warfarin therapy. The population included those with newly diagnosed atrial fibrillation who were eligible for treatment with warfarin. Compared with warfarin, apixaban, rivaroxaban, and dabigatran, costs were $93 063, $111 465, and $140 557 per additional quality-adjusted life year gained, respectively. At a threshold of $100 000 per quality-adjusted life year, apixaban provided the greatest absolute benefit while still being cost-effective, although warfarin would be superior if apixaban was 2% less effective than expected. Although apixaban was the optimal strategy in our base case, in probabilistic sensitivity analysis, warfarin was optimal in an equal number of iterations at a cost-effectiveness threshold of $100 000 per quality-adjusted life year.

CONCLUSIONS

While at a standard cost-effectiveness threshold of $100 000 per quality-adjusted life year, apixaban seems to be the optimal anticoagulation strategy; this finding is sensitive to assumptions about its efficacy and cost. In sensitivity analysis, warfarin seems to be the optimal choice in an equal number of simulations. As a result, although all the novel oral anticoagulants produce greater quality-adjusted life expectancy than warfarin, they may not represent good value for money.

Impact of CYP2C19 genetic testing on provider prescribing patterns for antiplatelet therapy after acute coronary syndromes and percutaneous coronary intervention

BACKGROUND

Patients treated with clopidogrel who have ≥1 loss of function alleles for CYP2C19 have an increased risk for adverse cardiovascular events. In 2010, the US Food and Drug Administration issued a boxed warning cautioning against the use of clopidogrel in such patients. We sought to assess the impact of CYP2C19 genetic testing on prescribing patterns for antiplatelet therapy among patients with acute coronary syndrome or percutaneous coronary intervention.

METHODS AND RESULTS

Patients with recent acute coronary syndrome or percutaneous coronary intervention prescribed clopidogrel were offered CYP2C19 testing. Genotype and phenotype results were provided to patients and their physicians, but no specific treatment recommendations were suggested. Patients were categorized based on their genotype (carriers versus noncarriers) and phenotype (extensive, intermediate, and poor metabolizers). The primary outcome was intensification in antiplatelet therapy defined as either dose escalation of clopidogrel or replacement of clopidogrel with prasugrel. Between July 2010 and April 2012, 6032 patients were identified, and 499 (8.3%) underwent CYP2C19 genotyping, of whom 146 (30%) were found to have ≥1 reduced function allele, including 15 (3%) with 2 reduced function alleles. Although reduced function allele carriers were significantly more likely than noncarriers to have an intensification of their antiplatelet therapy, only 20% of poor metabolizers of clopidogrel had their antiplatelet therapy intensified.

CONCLUSIONS

Providers were significantly more likely to intensify antiplatelet therapy in CYP2C19 allele carriers, but only 20% of poor metabolizers of clopidogrel had an escalation in the dose of clopidogrel or were switched to prasugrel. These prescribing patterns likely reflect the unclear impact and evolving evidence for clopidogrel pharmacogenomics.

The impact of medication adherence on coronary artery disease costs and outcomes: a systematic review

BACKGROUND

Given the huge burden of coronary artery disease and the effectiveness of medication therapy, understanding and quantifying known impacts of poor medication adherence for primary and secondary prevention is crucial. We sought to systematically review the literature on this topic area with a focus on quantified cost and clinical outcomes related to adherence.

METHODS

We conducted a systematic review of the literature between 1966 and November 2011 using a fixed search strategy, multiple reviewers, and a quality rating scale. We found 2636 articles using this strategy, eventually weaning them down to 25 studies that met our inclusion criteria. Three reviewers independently reviewed the studies and scored them for quality using the Newcastle Ottawa Scoring Scale.

RESULTS

We found 5 studies (4 of which focused on statins) that measured the impact of medication adherence on primary prevention of coronary artery disease and 20 articles that focused on the relationship between medication adherence to costs and outcomes related to secondary prevention of coronary artery disease. Most of these latter studies focused on antihypertensive medications and aspirin. All controlled for confounding comorbidities and sociodemographic characteristics, but few controlled for likelihood of adherent patients to have healthier behaviors ("healthy adherer effect"). Three studies found that high adherence significantly improves health outcomes and reduces annual costs for secondary prevention of coronary artery disease (between $294 and $868 per patient, equating to 10.1%-17.8% cost reductions between high- and low-adherence groups). The studies were all of generally of high quality on the Newcastle Ottawa Scale (median score 8 of 9).

CONCLUSIONS

Increased medication adherence is associated with improved outcomes and reduced costs, but most studies do not control for a "healthy adherer" effect.

Impact of a patient-centered pharmacy program and intervention in a high-risk group

BACKGROUND

The medication therapy management (MTM) program identified high-risk members in a large employer group and invited them to participate in an MTM program. The intervention consisted of at least 3 consultations with a clinical pharmacist to review and discuss drug therapy. The goal was to improve drug therapy adherence and clinical outcomes.

OBJECTIVE

To assess the impact of MTM on plan-paid health care costs, utilization of medical services, overall days supply of targeted medications, and medication possession ratios (MPRs).

METHODS

The MTM and control group comprised eligible members of a large employer prescription benefit plan who were identified between October 1, 2007, and November 12, 2008, and invited to participate. Control group members were selected from targeted members who declined. After propensity score matching to ensure similarity of groups at baseline, each group had 2,250 members. Baseline comparisons and post-period impact analyses between groups were conducted using bivariate analysis. Post-period analyses used tests for paired comparisons. The MTM and control group members were studied for the year before and after their individual program invitations. We measured pre-post differences between the MTM members and controls in total heath care costs, inpatient visits, emergency room (ER) visits, total days supply, and MPRs for 5 conditions: diabetes, hypertension, dyslipidemia, depression, and asthma.

RESULTS

MTM members significantly reduced their plan-paid health care costs by 10.3% or $977, compared with an increase of 0.7% or $62 in the control group (P = 0.048). Inpatient visits in the MTM group decreased by 18.6%, while the control group experienced an increase of 24.2% (P  less than  0.001). While both groups had decreases in ER visits, the groups were not significantly different (P = 0.399). Average days supply for the MTM group increased by 72.7 days over baseline; for the control group, it decreased by 111.1 days (P  less than  0.001). MTM members with hypertension and dyslipidemia had pre-post increases in MPR of 2.29% and 2.10%, respectively, while the control group had decreases of 2.31% and 2.61% (both P  less than  0.001). The mean MPRs for members with diabetes, depression, and asthma did not change in either group. Program costs per patient in 2009 were estimated to be $478. The program had a return on investment (ROI) of 2.0 in 2009.

CONCLUSIONS

This study found that the pharmacist-managed MTM program to reconcile the medication therapies of high-risk patients and improve adherence, as measured by MPR, was effective in reducing total health care costs. The results show that those patients in the intervention group with hypertension and dyslipidemia had significant improvements in medication adherence, as compared with the control group. In fact, the intervention group used significantly more days of therapy in the intervention period, and the control group used significantly fewer days than either group used during the baseline period. MTM interventions were associated with a significant decrease in the MTM members' overall plan-paid health care costs, driven largely by decreases in inpatient utilization and mediated by increases in average days supply and in MPR increases for hypertension and dyslipidemia. Overall, the MTM program was cost-effective. The ROI estimated for this program of 2.0 is only slightly lower than the average disease management ROIs reported in the literature.

Retail clinic utilization associated with lower total cost of care

OBJECTIVES

To better understand the impact of retail clinic use on a patient's annual total cost of care.

STUDY DESIGN

A propensity score matched-pair, cohort design was used to analyze healthcare spending patterns among CVS Caremark employees in the year following a visit to a MinuteClinic, the retail clinics inside CVS pharmacies.

METHODS

De-identified medical and pharmacy claims for CVS Caremark employees and their dependents who received care at a retail clinic between June 1, 2009, and May 31, 2010, were matched to those of subjects who received care elsewhere. High-dimensional propensity score and greedy matching techniques were used to create a 1-to-1 matched cohort that was analyzed using generalized linear regression models.

RESULTS

Individuals using a retail clinic had a lower total cost of care (-$262; 95% confidence interval, -$510 to -$31; P = .025) in the year following their clinic visit than individuals who received care in other settings. This savings was primarily due to lower medical expenses at physicians' offices ($77 savings, P = .008) and hospital inpatient care ($121 savings, P = .049). The 6022 retail clinic users also had 142 (12%) fewer emergency department visits (P = .01), though this was not related to significant cost savings.

CONCLUSIONS

This study found that retail clinic use was associated with lower overall total cost of care compared with that at alternative sites. Savings may extend beyond the retail clinic visit itself to other types of medical utilization.

An integrated pharmacy-based program improved medication prescription and adherence rates in diabetes patients

A substantial threat to the overall health of the American public is nonadherence to medications used to treat diabetes, as well as physicians' failure to initiate patients' use of those medications. To address this problem, we evaluated an integrated, pharmacy-based program to improve patients' adherence and physicians' initiation rates. The study included 5,123 patients with diabetes in the intervention group and 24,124 matched patients with diabetes in the control group. The intervention consisted of outreach from both mail-order and retail pharmacists who had specific information from the pharmacy benefit management company on patients' adherence to medications and use of concomitant therapies. The interventions improved patients' medication adherence rates by 2.1 percent and increased physicians' initiation rates by 38 percent, compared to the control group. The benefits were greater in patients who received counseling in the retail setting than in those who received phone calls from pharmacists based in mail-order pharmacies. This suggests that the in-person interaction between the retail pharmacist and patient contributed to improved behavior. The interventions were cost-effective, with a return on investment of approximately $3 for every $1 spent. These findings highlight the central role that pharmacists can play in promoting the appropriate initiation of and adherence to therapy for chronic diseases.