Order Pharmacy Use Research Articles

Associations between pharmacy choice and influenza vaccination: Mail order vs community pharmacy users.

BACKGROUND: Despite the effectiveness of vaccines, US adult vaccination rates remain low. This is especially true for the influenza vaccine, which is recommended annually and widely available. The accessibility of community pharmacies as convenient places to receive influenza vaccines has been shown to increase uptake. However, use of mail order pharmacies may reduce in-person pharmacist encounters and reduce the likelihood that users receive annual influenza vaccines. OBJECTIVE: To determine the association between the type of pharmacy a patient uses and their likelihood of receiving an influenza vaccine. METHODS: This cross-sectional cohort study used the 2018 Medical Expenditure Panel Survey to observe noninstitutionalized US adult pharmacy users. Pharmacy type was dichotomized into community use only vs any mail order pharmacy use. Multivariable weighted logistic regression was used to identify associations between the type of pharmacy used and influenza vaccination, adjusting for sociodemographic, health status, and health care access and utilization confounders. All analyses were stratified by age (< 65 and ≥ 65 years). RESULTS: The aged younger than 65 years and aged 65 years and older samples had 8,074 and 4,037 respondents who represented 95,930,349 and 40,163,276 weighted observations, respectively. Compared with community pharmacy users, mail order users were more likely to be aged 65 and older, be White, have high income, and have a usual source of care (P < 0.0001). Adjusted odds ratios (AORs) for influenza vaccination were significantly lower among community pharmacy users than mail order users among individuals aged younger than 65 years (AOR=0.71; 95% CI = 0.580.87) but was not significant among those aged 65 years and older (AOR = 0.87; 95% CI = 0.69-1.09). CONCLUSIONS: Community pharmacy users aged younger than 65 years are less likely to receive the influenza vaccine than their mail order pharmacy user counterparts. These counterintuitive results could be caused by residual confounding due to differences in factors that influence pharmacy use type and vaccination likelihood. Further exploration is needed to account for differences between these populations that independently drive vaccination choice. DISCLOSURES: Dr Burbage was a fellow in the Real World Evidence, Population Health and Quality Research Postdoctoral Fellowship Program in collaboration with University of North Carolina Eshelman School of Pharmacy and Pharmacy Quality Alliance, and supported by Janssen Scientific Affairs at the time of this study. She is now employed by Janssen Scientific Affairs. Dr Parikh is an employee of Pharmacy Quality Alliance. Dr Campbell was employed by Pharmacy Quality Alliance at the time of the study. He is now employed by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. Dr Ramachandran has received an unrelated research contract with Pharmacy Quality Alliance. Dr Gatwood has received vaccine-related research grants from Merck & Co. and GlaxoSmithKline unrelated to this project and consulting fees for a vaccine-related expert panel with Merck & Co. unrelated to this manuscript and is an advisory board member with Janssen Scientific Affairs. Dr. Urick was employed by the UNC Eshelman School of Pharmacy at the time of this writing and is currently employed by Prime Therapeutics. He has received community pharmacy-related consulting fees from Cardinal Health and Pharmacy Quality Solutions unrelated to this work. Dr Ozawa has a research grant from Merck & Co. unrelated to this project. This project did not receive funding from any agency in the public, commercial, or not-for-profit sectors.

Medication delivery factors and adjuvant endocrine therapy adherence in breast cancer.

Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.

A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes.

Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. To assess an intervention to encourage MOP services to increase its use and medication adherence. Randomized encouragement trial. 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12months. Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients. ClinicalTrials.gov registration number: NCT02621476.

Factors associated with adjuvant endocrine therapy adherence in non-metastatic breast cancer.

533 Background: Over 50% of breast cancer patients prescribed adjuvant endocrine therapy (ET) are nonadherent during the recommended 5-year course of therapy. We investigated the role of cancer medication delivery on adherence, including mail order pharmacy use, number of pharmacies and copays. Methods: We conducted a retrospective cohort study of 15,769 commercially insured breast cancer patients age 18-64 with newly diagnosed breast cancer in 2007-2015 that initiated ET. Incident breast cancer was identified by a validated algorithm which identifies mainly non-metastatic breast cancer. We examined the association between 12-month AET adherence (proportion of days covered by fills ≥0.80) and mail order pharmacy use, number of pharmacies, and AET copays. We used Poisson regression to estimate nonadherence risk ratios and adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments (surgery, radiation, chemo, and ET initiated), and generic AI availability. Sensitivity analyses were conducted using alternate specifications for independent variables. To test whether any observed differences were due to self-selection, we also conducted a negative control analysis. Results: Most patients were white (74.4%) and age 55-64 (43.3%). Only 16% of patients used a mail order pharmacy for ET fills, most patients only used one pharmacy (58.8%) and 25.2% had a co-pay of $20 or more. In the primary analysis, mail order patients were more likely to be adherent to their ET (aRR 1.21; 95% CI 1.18-1.24), patients using one pharmacy were more likely to be adherent (1 vs 3+: aRR 1.09; 95% CI 1.06-1.13), and patients with lower copays were more likely to be adherent (quartile 1 vs 4: aRR 1.04; 95% CI 1.01-1.08). Results were consistent across sensitivity analyses, and there was no association between mail order and copays and the negative control outcome of any pneumonia diagnoses. Conclusions: Medication delivery factors are associated with adherence to breast cancer AET. Future work should investigate whether interventions to streamline medication delivery could improve adherence for this population.

Impact of mail order pharmacy use and travel time to pharmacy on viral suppression among people living with HIV

ABSTRACT This study aimed to evaluate the impact of mail order pharmacy services and travel time to pharmacy on HIV viral suppression rates among people living with HIV. For adult patients receiving HIV care from 2010 to 2015 at an urban HIV care clinic, we collected demographics, pharmacy type, viral load, and patient home and pharmacy address. We geocoded addresses and measured travel time to pharmacy by car and public transportation. No difference was observed in recent viral suppression rates based on pharmacy type (p = 0.41), distance to pharmacy (p = 0.16), or travel time to pharmacy by car (p = 0.20) or public transportation (p = 0.15). The only factors significantly associated with sustained viral suppression were number of doses per day of antiretroviral therapy, with patients prescribed twice daily regimens less likely to be virally suppressed than those prescribed once daily regimens (aOR 0.4, 95% CI, [0.1, 0.6]) and average household income in patients’ zip code, with patients living in zip codes with average household income <$40,000 per year less likely to be virally suppressed than those living in zip codes with average income >$55,000 per year (aOR 0.2. 95% CI, [0.1, 0.7]).

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study

BackgroundMedication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional “brick and mortar” pharmacies to refill prescriptions.MethodsWe conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software.ResultsA total of 28 diabetes patients participated. Participants’ average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of ‘Opportunity.’ Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions.ConclusionsThis study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

169-LB: A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence

Medication non-adherence is a major contributor to poor diabetes outcomes. Observational studies show positive associations between mail order pharmacy (MOP) use and adherence, and suggest that mail order is cost-saving to patients. However, no prospective trials have examined the effect of encouraging MOP use on medication adherence. We conducted a randomized encouragement trial in 2017 in three health plans: Kaiser Permanente (KP) Northern California, KP Hawaii, and Harvard Pilgrim Health Care (HPHC). Patients were eligible if they had diabetes, poor adherence (Proportion of Days Covered &amp;lt;80%) to at least one class of cardiometabolic medications, and had not used MOP in the prior 12 months. Patients were randomized to receive either no intervention (controls) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use for diabetes patients; HPHC intervention patients received the letter only. We compared the percentages of patients in both arms that began using mail order and that became adherent to cardiometabolic medication classes during the 12-month follow-up. A total of 63,012 patients were included: mean age was 60; 45% were female; 41% were non-Hispanic white; 12% were black; 25% were Hispanic/Latino, and 22% were Asian/Native Hawaiian/Pacific Islander. During follow-up, 12% of intervention patients used the mail order pharmacy vs. 10% of controls (p&amp;lt;.001); the percent of cardiometabolic medications delivered via mail was 42% vs. 39% (p&amp;lt;.01). Metformin adherence improved in the intervention group relative to controls at the two KP sites (52% vs. 49%, p&amp;lt;.01). This randomized trial shows that simple outreach to encourage MOP use modestly improved its use, and improved adherence to a key class of diabetes medications in some settings. Clinicians and health systems should consider such low-cost interventions to actively promote MOP among diabetes patients. Disclosure J. Schmittdiel: None. C.M. Trinacty: None. J. Wharam: None. O. Duru: Advisory Panel; Self; Healthwise. R. Neugebauer: None. S.D. Brown: None. D. Ross-Degnan: None. A.J. Karter: None. W.T. Dyer: None. B. Ramachandran: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

1904. Impact of Mail Order Pharmacy Use on Viral Suppression Among HIV-Infected Patients

BackgroundThere are many barriers to adherence to antiretroviral medications, including pharmacy accessibility. Few studies have evaluated the impact of pharmacy distance or use of mail order pharmacy services on HIV viral load suppression relative to use of an “in-person” pharmacy. The purpose of our study was to determine whether there is a difference in viral suppression rates among patients who utilize mail order pharmacy services vs. an in-person pharmacy for filling antiretroviral prescriptions. Our study also looked at the effect of distance and travel time to viral suppression for patients who use in-person pharmacy services.MethodsThis was a single-center, retrospective cohort study of adult HIV-positive patients who received care between 2006 and 2015 at an urban HIV care clinic. We collected patient demographic information, ART regimen, home address, pharmacy address, and laboratory values. For patients who utilized retail pharmacies, patients’ home addresses and the location of the pharmacy were geocoded using ESRI’s StreetMap Premium geocoding service. We calculated patients’ travel distance to pharmacy and travel time to pharmacy along a street network in a private vehicle. Chi-squared tests and logistic regression were used to determine the association between in-person or mail order pharmacy services and distance to pharmacy and viral suppression (viral load ≤200 copies/mL).ResultsThere were 214 patients in the mail order group and 214 patients included the in-person pharmacy group. Baseline characteristics were similar between the groups, with the exception of more people who inject drugs in the mail order group (6.1% vs. 1.8%, P = 0.05). No difference in viral load suppression was observed between groups (21.7% vs. 20.2%, P = 0.679). There was no difference in viral suppression depending on the distance (1.46 miles away in viral suppressed patients vs. 1.36 miles, P = 0.75) or travel time to pharmacy (7 minutes vs. 6.6 minutes, P = 0.75) for the in-person pharmacy group. Factors found to be significantly associated with suppressed viral loads were older age, white race, and higher CD4 counts.ConclusionViral suppression was not associated with pharmacy type, distance to pharmacy, or travel time to pharmacy.Disclosures All authors: No reported disclosures.

Mail order pharmacy use and adherence to secondary prevention drugs among stroke patients

Background and purposeMail order pharmacies (MOP) are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or even greater medication adherence than local pharmacy (LP) use. We are unaware of any studies that have evaluated the association of mail order pharmacy use with drug adherence among stroke patients. MethodsWe conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals in a managed care network, who received a new anticoagulant, antiplatelet, anti-glycemic, antihypertensive, and/or lipid-lowering medication between January 1, 2007 and June 30, 2015. We defined good adherence as medication availability ≥80% of the time, and compared adherence between mail-order users (≥66% of refills by mail) and local pharmacy users (all refills in person). Relationship between delivery method and adherence was evaluated using multivariate regression models. ResultsA total of 44,658 eligible patients refilled an index medication. Of these, 13,295 in the LP and 6801 in MOP groups met inclusion criteria. Patients in the MOP group were more likely to be white, and less likely to have hypertension, diabetes, and smoke tobacco. Continuous Medication Gap (CMG) adherence was 0.28 in the LP group and 0.11 in the MOP group (p < 0.001). At 90-days there were 893 hospital readmissions for the LP group and 375 for the MOP group for a rate of 0.07 vs 0.06 (p < 0.001). In the multivariable analysis, adherence was associated with MOP use, (OR 0.12, 95% CI 0.11–0.14) and decreased readmission at 90 days (OR 0.62, 95% CI 0.55–0.71). ConclusionsStroke patients who use MOP vs. LP are more likely to have good medication adherence. Future studies should examine the impact of mail-order pharmacy use on vascular risk marker control and events after stroke.

Adherence and persistence to ropinirole, pramipexole, and gabapentin in patients with newly diagnosed restless legs syndrome

Study objectivesThe objective of this study is to assess adherence and persistence of ropinirole, pramipexole, and gabapentin; to investigate factors associated with non-adherence and non-persistence in restless legs syndrome (RLS) patients. MethodsWe used the 2008–2014 Marketscan® Research Databases to conduct a retrospective data analysis. The study included newly diagnosed RLS patients who initiated ropinirole, pramipexole, or gabapentin therapy. During 365 days of follow-up, mean medication possession ratios (MPRs) for adherence and the proportion of adherent users were calculated. The mean persistence (time to discontinuation) and the proportion of persistent users were also assessed during the same follow-up period. Factors associated with non-adherence and non-persistence were analyzed using multivariate logistic regression. ResultsThis study included 5163 ropinirole, 3380 pramipexole, and 1353 gabapentin users. The mean MPRs for ropinirole, pramipexole, and gabapentin were 0.52, 0.52, and 0.48, respectively. The proportions of adherent users were 33.2%, 34.6%, and 27.4%, respectively. Mean time to treatment discontinuation was 158 days, 158 days, and 145 days, respectively. The proportions of persistent users at 365 days were 25.0%, 25.8%, and 20.6%, respectively. Younger age, higher number of concomitant medications, and gabapentin use (vs. ropinirole or pramipexole use) were positively associated with non-adherence and non-persistence. Additionally, retail pharmacy use (vs. mail order pharmacy use) and use of benzodiazepines were positively associated with non-adherence. ConclusionAdherence and persistence to ropinirole, pramipexole, and gabapentin were low in newly diagnosed RLS patients during 365 days of follow-up. Certain patient characteristics were predictors of non-adherence and non-persistence.

Mail order pharmacy use in dermatologic disease: Are patients finding value?

Mail order pharmacy use in dermatologic disease: Are patients finding value?

Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE).

To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012. Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. Adherence and OOP costs were based on pharmacy dispensing records and benefits. Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p<.0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24months). Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

Abstract TMP101: Mail Order Pharmacy Use is Associated With Greater Adherence to Secondary Preventive Medications and Lower Hospital Readmission Among Stroke Patients

Background: Mail order pharmacies (MOP) are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or greater medication adherence than local pharmacy (LP) use. Medication adherence is associated with improved outcomes, including reduced cardiovascular events, health care costs, and mortality. We are unaware of any studies that have evaluated the association of MOP use with medication adherence among stroke patients. Objective: To investigate whether stroke patients who use MOPs were more likely to have good medication adherence than those who used LPs and whether adherence was associated with 90 day hospital re-admission after stroke. Methods: We conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals who received a new anticoagulant, antiplatelet, antiglycemic, antihypertensive, and/or lipid-lowering medication between 01/JAN/2007 and 30/JUL/2016. We compared adherence between MOP users (at least 66% of refills by mail) and LP users (all refills in person). Adherence was calculated by using the Continuous Medication Gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication is divided by the number of days in the study window for that patient. A CMG adherence score of 0 meant that the patient had no overall gaps in their medications (perfect adherence), a negative number meant that the patient had more medication than days, and a positive number meant that the patient did not have enough medication for the days they should be taking their medication (poor adherence). Results: A total of 44,658 eligible patients refilled an index medication. Of these, 13,676 in the LP and 6,907 in MOP group met inclusion criteria. CMG adherence was 0.28 in the LP group and 0.11 in the MOP group ( p &lt; 0.001). At 90-days there were 893 hospital readmissions for the LP group and 375 for the MOP group for a rate of 0.073 vs. 0.058 (p &lt; 0.001). Conclusions: Stroke patients who obtain medication by mail are more likely to have good adherence, and less likely to be readmitted than those who obtain medications from their local pharmacies.

Abstract 189: Mail Order Pharmacy Use is Associated with Greater Adherence to Secondary Preventive Drugs Among Stroke Patients

Background: Mail order pharmacies are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or even greater medication adherence than local pharmacy use. Medication adherence is associated with improved outcomes, including reduced cardiovascular events, health care costs, and mortality. We are unaware of any studies that have evaluated the association of mail order pharmacy use with drug adherence among stroke patients. Objective: To investigate whether stroke patients who use mail-order pharmacies were more likely to have good medication adherence than those who used local pharmacies. Methods: We conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals who received a new anticoagulant and/or lipid-lowering medication between 31/DEC/2006 and 26/JUN/2015. We defined good adherence as medication availability at least 80% of the time (i.e, a continuous measure of medication gaps value of less than or = 20%) and compared adherence between mail-order users (at least 66% of refills by mail) and local pharmacy users (all refills in person). Adherence was calculated from the initial dispensing based on the average percentage adherence and days between fills. Results: A total of 48,746 eligible patients refilled an index medication. There were 205,085 prescriptions for statins (136,722 by pharmacy and 68,363 by mail), and 50,483 prescriptions for anticoagulants (34,682 by pharmacy and 15,801 by mail). Overall, patients were adherent 46.48% of the time if they picked up their prescriptions from the pharmacy versus 73.87% of the time if they had their prescriptions mailed to them (p &lt;.0001). Compared with those who only used local pharmacies, patients who received medications by mail were more likely to have good adherence to lipid modifiers (87.61% vs. 56.4%, OR 5.43, 95% CI = 5.3 - 5.57, p &lt; .0001) and anticoagulants (44.88% vs. 56.16%, OR 1.57 95% CI 1.52 - 1.63, p &lt; .0001). Conclusions: Stroke patients who obtain medication by mail are more likely to have good medication adherence than those who obtain them from local pharmacies. Future studies should examine the impact of mail-order pharmacy use on vascular risk marker control and events after stroke.

Health care system-level factors associated with performance on Medicare STAR adherence metrics in a large, integrated delivery system.

Background:The Centers for Medicare and Medicaid Services provide significant incentives to health plans that score well on Medicare STAR metrics for cardiovascular disease risk factor medication adherence. Information on modifiable health system-level predictors of adherence can help clinicians and health plans develop strategies for improving Medicare STAR scores, and potentially improve cardiovascular disease outcomes.Objective:To examine the association of Medicare STAR adherence metrics with system-level factors.Research Design:A cross-sectional study.Subjects:A total of 129,040 diabetes patients aged 65 years and above in 2010 from 3 Kaiser Permanente regions.Measures:Adherence to antihypertensive, antihyperlipidemic, and oral antihyperglycemic medications in 2010, defined by Medicare STAR as the proportion of days covered ≥80%.Results:After controlling for individual-level factors, the strongest predictor of achieving STAR-defined medication adherence was a mean prescribed medication days’ supply of >90 days (RR=1.61 for antihypertensives, oral antihyperglycemics, and statins; all P<0.001). Using mail order pharmacy to fill medications >50% of the time was independently associated with better adherence with these medications (RR=1.07, 1.06, 1.07; P<0.001); mail order use had an increased positive association among black and Hispanic patients. Medication copayments ≤$10 for 30 days’ supply (RR=1.02, 1.02, 1.02; P<0.01) and annual individual out-of-pocket maximums ≤$2000 (RR=1.02, 1.01, 1.02; P<0.01) were also significantly associated with higher adherence for all 3 therapeutic groupings.Conclusions:Greater medication days’ supply and mail order pharmacy use, and lower copayments and out-of-pocket maximums, are associated with better Medicare STAR adherence. Initiatives to improve adherence should focus on modifiable health system-level barriers to obtaining evidence-based medications.

PHS112 - Mail Order Pharmacy Use And Associated Health Expenses In Adults With Diabetes

PHS112 - Mail Order Pharmacy Use And Associated Health Expenses In Adults With Diabetes

Opinions of a small sample of pharmacists about pharmacy setting and patient adherence to antiretroviral therapy.

Many private and public health insurance plans increasingly encourage their beneficiaries—either through mandates or incentives—to fill prescriptions for longterm chronic conditions through a mail order pharmacy or at a community-based or mail order specialty pharmacy designated by the pharmacy benefit manager. Approximately 90% of employers as of May 2011 and 25 state acquired immune deficiency syndrome (AIDS) Drugs Assistance Programs (ADAPs) for uninsured and underinsured persons living with human immunodeficiency virus (HIV) as of June 2010 offered a mail order service option; 18% of employers and 17 of the 25 ADAPs mandated the use of mail order pharmacy for chronic medications. Although the shift to mail order pharmacy may have been motivated by perceived economic benefits of mail order, including improved efficiency and reduced prescription drug costs accruing to payers, there is evidence to suggest that mail order pharmacy use is associated with improved adherence because of greater convenience. However, a study by Khandelwal et al. (2011) found only a 1 percentage point difference in medication possession ratio (MPR) comparing patients receiving 90-day supplies dispensed in community versus mail order pharmacies, and a study by Liberman et al. (2011) found that mandatory mail order benefit design was associated with decreased patient adherence. Health plans may require use of specialty pharmacy distribution channels for costly medications associated with complex management issues, including medication adherence, because of a belief that the “high-touch” services offered by specialty pharmacies (e.g., patient education, identification of sources of financial assistance) provide a therapeutic benefit to the patient. Of the 74% of employers that offered a specialty pharmacy benefit in May 2011, 48% required specialty drugs to be channeled through a designated specialty pharmacy (either community-based or mail order). Similarly, 14 ADAPs used central pharmacy distribution, and 18 ADAPs had designated ADAP pharmacies for pick-up in June 2010. Adherence to antiretroviral therapy (ART) is a challenge for persons living with HIV (PLWH), with an estimated 40% dropping out of care within the first 2 years of starting treatment. In a variety of therapeutic classes, inconsistent adherence is associated with poor clinical outcomes, treatment failure, and increased health care costs. In general, patients utilizing specialty community pharmacies receive more personalized care and have better adherence rates compared with those in nonspecialty community pharmacies. A pilot study found that Medi-Cal beneficiaries with HIV who received medication therapy management (MTM) in community pharmacies that specialized in providing HIV-intensive MTM services had higher adherence rates that persisted over 3 years, compared with patients in pharmacies not providing these services. Although the dispensing of 90-day prescription supplies in community pharmacies is generally increasing, mail order pharmacy may be appropriate for PLWH who are stabilized on therapy and comfortable with their medication regimens, and may be more attractive than community-based pharmacy services for those patients who prefer online ordering of medication. The impact of mail order pharmacy compared with community-based pharmacy on ART adherence is unknown. While the primary focus in the pharmacy literature and in public health and insurance policy decision making has been differences between mail order and community-based specialty versus traditional pharmacies, less is known about the adherence promotion practices of specialty mail order and community pharmacies. In particular, little research attention has focused on adherence promotion activities in mail order settings offering differentiated products—traditional versus specialty mail order—or compared adherence promotion practices and patient health outcomes in community-based specialty and mail order specialty pharmacies. This information might be important in light of a recent pharmaceutical industry report that 60% of employers are covering 90-day supplies of maintenance medications in community pharmacies, and 90% offered mail order pharmacy services. Khandelwal et al. found that patients filling 90-day supplies of maintenance medications (e.g., antiasthmatics, antidiabetics, diuretics) in community-based pharmacies had a slightly higher mean medication possession ratio compared with those who filled their prescriptions by mail order (77.0% vs. 76.0%, respectively). Patwardhan et al. (2011) found slightly higher adherence rates and a reduced rate of gaps in therapy exceeding 30 days among patients filling prescriptions at a worksite pharmacy compared with mail order service and attributed this finding in part to the pharmacist-patient interaction.

The Comparative Effectiveness of Mail Order Pharmacy Use vs. Local Pharmacy Use on LDL-C Control in New Statin Users

Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes. To examine the comparative effectiveness of mail order pharmacy vs. local pharmacy use on LDL-C control in new statin users. Observational cohort study. 100,298 adult Kaiser Permanente Northern California (KPNC) members who were new users of statins between January 1, 2005 and December 31, 2007. The main outcome measure was LDL-C control in the 3-15 month period after statin therapy was initiated. After adjustment for patient, clinical, and census-block characteristics, and for potential unmeasured differences between mail order and local KPNC pharmacy users with instrumental variables analysis, 85.0% of patients who used the mail order pharmacy to deliver their statin at any time achieved target LDL-C levels compared with 74.2% of patients who only used the local KPNC pharmacy to dispense the statin (p < 0.001). Greater adjusted rates of LDL-C control in mail order pharmacy users were seen across all gender and race/ethnicity subgroups. Mail order pharmacy use was positively associated with LDL-C control in new statin users. Future research should continue to explore the relationship between mail order pharmacy use and outcomes, and address how to appropriately target mail order services to patients most likely to benefit without compromising patient choice, care, and safety.