Refill Service Research Articles

Improving Timely Medication Access for Endocrinology and Diabetes Patients: A Quality Improvement Initiative

ABSTRACT Introduction Managing chronic conditions such as endocrinology and diabetes requires consistent access to medications. Traditional methods of medication refill often involve in-person visits to healthcare providers or pharmacies, posing challenges for patients. Online medication refill services offer a promising solution to improve accessibility and convenience. Methods This is a digital-based solution using online medication refill services to enhance the management of endocrinology and diabetes medication refills. It examines the process of online medication refill, including patient registration, refill request submission, verification, provider input, processing, and pickup or delivery. Results Online medication refill services empower patients to easily request refills from the comfort of their homes, streamlining the refill process, and reducing walk-in pressure in clinics. The online medication refill with the option for home delivery option eliminates the need for patients to visit the hospital, further enhancing the patient experience. Before implementing the online medication refill solution, 26 patients will come to the clinic as walk-ins to request medication refills. The average waiting time for each patient is 45 minutes. Each provider will be interrupted for an average of 10 minutes to accommodate the request. The overall processing time required for each walk-in patient to submit the medication request is 1 hour on average. After implementing the online medication refill intervention, zero patients come to the clinic as walk-ins and hence, no interruption to the daily regular clinics. The overall processing time required for submitting the online medication request is now 2 minutes. These interventions promote medication adherence and patient engagement by facilitating access to medications and offering educational resources. Conclusion Online medication refill services represent a valuable tool in the comprehensive management of endocrinology and diabetes. They offer accessibility, convenience, and patient empowerment, potentially improving health outcomes and enhancing the overall patient experience.

Updates to a pharmacy-technician driven centralized medication refill service in a large community health system

In 2020, we published a description of the newly implemented centralized refill service (CRS) led by pharmacy technicians in our large community health system. Since that time, the CRS has been refined, updated, and expanded. We have also received many inquiries with common questions about the process from those who seek to implement a similar process. The purpose of this commentary is to 1) provide updates to the process in the 5 years since its implementation, and 2) provide additional insights on specific topics from inquiries to the organization.

Exploring adolescent girls and young women's PrEP-user profiles: qualitative insights into differentiated PrEP delivery platform selection and engagement in Cape Town, South Africa.

Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre-exposure prophylaxis (PrEP). With ongoing PrEP scale-up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16-25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community-based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light-touch PrEP refill services incorporating rapid HIV self-testing. We conducted in-depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP-use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision-making and habits related to PrEP access to inform market segmentation. We interviewed 26 AGYW (median age 20) PrEP-users between November 2020 and March 2021. AGYW PrEP-users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The "Social PrEP-user" preferred PrEP delivery in peer spaces, such as youth clubs or adolescent-friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The "Convenient PrEP-user" favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception-PrEP refill visits (mobile and government clinic). The "Independent PrEP-user" preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The "Discreet PrEP-user" highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self-testing had minimal influence on PrEP delivery choice. Market segmentation of AGYW characterizes different types of PrEP-users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits.

Intersecting Epidemics: The Predictors of Continued Utilization of HIV Care and Treatment Services During the COVID-19 Outbreak Among People Living with HIV in ZIMBABWE

Globally, there have been considerable achievements towards HIV care and treatment. AIDS-related deaths have been reduced by 60% since the peak in 2004. Potentially, the fight against the HIV epidemic was made more difficult with the outbreak of COVID-19. Thus, this study examined the implications of COVID-19 in the utilization of HIV care and treatment services among people living with HIV on antiretroviral therapy (ART) in Zimbabwe. The study aimed to identify the critical factors defining the utilization of HIV services at the advent of COVID-19 using the fifth revision of the Anderson Behavioral Model of Healthcare Utilization. The study utilized a concurrent triangulation design of which only one data collection phase was used. The quantitative data was collected from 2,157 people living with HIV on antiretroviral viral therapy through a structured interviewer-administered questionnaire. On the other hand, qualitative data was collected through in-depth interviews. Regarding accessing ART refills, the study findings revealed that adolescents aged 15–19 (aOR = 2.16; 95% CI: 1.18–3.96) had higher odds of utilizing ART refills compared to their counterparts who were aged 20–24. Living in a rural area was associated with higher odds of utilizing the ART refill service (aOR = 2.20; 95% CI: 1.49–3.24). Regarding accessing viral load monitoring adults aged 25–39 (aOR = 0.41; 95% CI: 0.26–0.66) were less likely to utilize viral load monitoring compared to young people aged 20–24. Being vaccinated for COVID-19 was significantly associated with higher odds of utilizing the viral load monitoring service (aOR = 1.97; 95% CI: 1.36–2.87) than those not yet vaccinated. Living in a rural area was associated with higher odds of utilizing viral load monitoring (aOR = 1.50; 95% CI: 1.09–2.08). Regarding tuberculosis preventative therapy, adults aged 25–39 (aOR = 0.30; 95% CI: 0.20–0.47) were less likely to utilize tuberculosis preventative therapy compared to young people aged 20–24. Being vaccinated for COVID-19 was significantly associated with higher odds of utilizing tuberculosis preventative therapy (aOR = 1.59; 95% CI: 1.12–2.25) than those not yet vaccinated. Living in a rural area was associated with higher odds of utilizing tuberculosis preventive therapy (aOR = 1.58; 95% CI: 1.19–2.08). Regarding tuberculosis screening being vaccinated for COVID-19 was significantly associated with higher odds of utilizing tuberculosis screening services (aOR = 1.89; 95% CI: 1.41–2.54) than those not yet vaccinated. Although the severity of the COVID-19 pandemic has dwindled, COVID-19 appears to come and go in waves, and a few countries are still recording relatively high cases. It is therefore likely that the factors associated with utilization of HIV services identified by the study such as age, residence, type of health facility, vaccination of COVID-19 and fear of contracting COVID-19, among others, need to be included when planning to improve access to health utilization.

Development and validation of an assessment tool for public perceptions toward drive-thru community pharmacy services in Malaysia during COVID-19.

Community pharmacists' roles have expanded and undergone a significant transition over the last few years. Consequently, new and different pharmacy services, such as drive-thru pharmacy services, have emerged. Drive-thru pharmacy services began three decades ago and continued even during outbreaks such as the COVID-19 pandemic. Patients' perceptions are essential to the successful implementation and satisfaction with any new service. This study examines the reliability and validity of the assessment tool of public perceptions toward drive-thru community pharmacy services in Malaysia during COVID-19. A cross-sectional study was conducted. The developed tool consists of 28 items to evaluate believed advantages toward drive-thru community pharmacy services, believed disadvantages toward drive-thru community pharmacy services, differences between drive-thru community pharmacy services and instore drug refill services, perceptions toward drive-thru community pharmacy services and feelings regarding how the introduction of drive-thru pharmacy services may affect the image of community pharmacists. Exploratory factor analysis (EFA) was performed to identify the factors of the developed tool, and confirmatory factor analysis (CFA) evaluated the model fitness. The EFA identified five elements and 25 items for the tool, and through CFA results, the observed model of the 25 items structure of the tool was verified as an excellent fit for the data [χ2 (265, N = 565) = 819.586, p < 0.001, IFI = 0.931, CFI = 0.93, RMSEA = 0.064]. The results of the CFA indicated a good model fit between the observed model and the proposed model. The internal reliability of the entire tool and each factor was very satisfactory as Cronbach's Alpha for the whole structured tool was 0.843 and for each factor was as follows, first factor (believed advantages) = 0.909, second factor (believed disadvantages) = 0.921, third factor (differences between drive-thru and instore refill) = 0.647, fourth factor (perceptions) = 0.926, and fifth factor (feelings) = 0.681. The developed and validated tool would be valuable for assessing the public's perceptions of the drive-thru community pharmacy service during COVID-19 and future pandemics.

Pharmacist-Managed Refill Service Impacts on Clinician Workload and Medication Interventions in a Federally Qualified Health Center.

Increasing administrative workload is linked with lower quality of patient care and physician burnout. Conversely, models involving pharmacists can positively impact patient care and physician well-being. Research has consistently demonstrated that pharmacist-physician collaboration can improve outcomes for chronic diagnoses. Pharmacist-managed refill services may improve provider workload measures and clinical outcomes. This was an evaluation of a pharmacist-managed refill service at a Federally Qualified Health Center (FQHC). Under collaborative practice agreement, pharmacists addressed refill requests and recommended interventions. Data analysis evaluated effectiveness of the model, including clinical interventions, and involved descriptive statistics and qualitative approaches. Average patient age was 55.5 years old and 53.1% were female. Turnaround time was within 48 h for 87.8% of refill encounters. During an average of 3.2 h per week, pharmacists addressed 9.2% (n = 1683 individual requests in 1255 indirect patient encounters) of the total clinic refill requests during the 1-year study period. In 453 of these encounters (36.1%), pharmacists recommended a total of 642 interventions. 64.8% of these were need for appointment (n = 211) or labs (n = 205). Drug therapy problems and medication list discrepancies were identified in 12.6% (n = 81) and 11.9% (n = 76) of encounters, respectively. The results of this study are consistent with previous literature demonstrating the value of interprofessional collaboration. Pharmacists addressed refills in an efficient, clinically effective manner in an FQHC setting. This may positively impact primary care provider workload, patients' medication persistence, and clinical care.

Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa.

IntroductionCommunity‐based delivery of HIV pre‐exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home‐based services and pop‐up tents into existing community‐based HIV testing services (CB‐HTS) in Eastern Cape Province, South Africa.MethodsAfter accessing CB‐HTS via a “pop‐up” tent or home‐based services, HIV‐negative AGYW aged 16–25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community‐based PrEP site co‐located with pop‐up HTS tents. A 30‐day supply of PrEP was dispensed. PrEP uptake, time‐to‐initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics.ResultsOf the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community‐based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop‐up HTS and 142/323 [44.0%] from home‐based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home‐based HTS, 59.1% initiated within 0–3 days, 25.6% within 4–14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop‐up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self‐perception of HIV risk, post‐hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP.ConclusionsLeveraging CB‐HTS platforms to provide same‐day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co‐located with CB‐HTS sites compared to those referred following home‐based HTS, suggesting that proximity of CB‐HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community‐based service delivery will be crucial to maintaining access to PrEP services during the COVID‐19 pandemic and future health and humanitarian emergencies.

Racial and Geographic Disparities in Endocrine Therapy Adherence Among Younger Breast Cancer Survivors.

African American (AA) women with breast cancer (BrCA) have higher mortality than any other race. Differential mortality has been attributed to nonadherence to endocrine therapy (ET). ET can lower the risk of dying by one third; yet 50% to 75% of all women are nonadherent to ET. Despite the wealth of research examining adherence to ET, understanding which groups of women at risk for poor adherence is not well established. The aim of this investigation was to describe ET adherence by race and geographic location among a cohort of younger BrCA survivors. Cancer registry records were linked to administrative data from Medicaid and a private insurance plan in South Carolina. Inclusion criteria included: European American (EA) or AA race, 3 years of continuous enrollment in the insurance plan after diagnosis, and BrCA diagnosis between 2002 and 2010. Adherence was measured by computing a medication possession ratio (MPR) based upon refill service dates and the number of pills dispensed. Adjusted least squared means were calculated by racial and geographic group using analysis of covariance methods. The average MPR for EA women was significantly higher at 96% compared with 92% for AA women (P<0.01). After adjustment for years on hormone therapy, age, and number of pharmacies utilized, rural AA women had an average MPR of 90% compared with 95% for EA women (P<0.01). AA women residing in rural areas demonstrate significantly lower adherence compared with their EA counterparts. Interventions are needed to improve adherence that may ameliorate AA mortality disparities.

CV2 - Identification of Low Risk Stable Cardiovascular Patients and Patient Acceptance for Fast-Track Medication Refill (FTMR) Service

This study aims to identify characteristics of patients who do not require medication change in a follow-up visit and thus are eligible to be offloaded for FTMR where patients could obtain their repeat medications from pharmacists. This study also aims to identify patient acceptance of this proposed service. Medical records of patients attended the Hypertension Clinic in Prince of Wales Hospital from April 2016 to March 2017 were collected and their relationships with medication change were analyzed by logistic regression. A questionnaire survey capturing patient satisfactions of the current waiting time and their acceptances of FTMR was conducted from January to March 2017. Multivariate logistic regressions performed using patient characteristics (N = 472) revealed that a higher HbA1C level (OR = 4.88), and presence of dizziness or syncope (OR = 3.04) and side-effects (OR = 3.19) increase the odds to changing HbA1C-lowering medications. A shorter time-within-therapeutic-range (TTR) for BP (OR = 0.22), a larger BP-therapeutic goal difference (OR = 0.91), male gender (OR = 2.76), and presence of ankle swelling (OR = 33.94), chest pain (OR = 2.16), palpitation (OR = 43.26), and side-effects (OR = 142.45) increase the odds to changing BP-lowering medications. A higher LDL level (OR = 3.51), a smaller LDL-TTR multiplication product (OR = 0.68), and presence of chest pain (OR = 31.82) and side-effects (OR = 8.45) increase the odds to changing LDL-lowering medications.The questionnaire survey (N = 92) revealed 59.78% of interviewees expressed preference for FTMR if their medication refills are to be authorized by a physician. Characteristics of patients not requiring medication change were identified. These patients are potential candidates for our proposed FTMR service, which is prefered by a majority of patients as a way to improve their satisfactions to the medical care.

Pharmacist-managed short-acting beta agonist refill service in a general pediatric clinic

ObjectivesTo use a pharmacist-managed short-acting beta agonist (SABA) service (1) to determine the patient’s rationale for SABA refill requests, (2) to assess adherence to current controller therapy and current level of disease control, and (3) to characterize the pharmacist’s recommendations made in response to a patient’s SABA refill request. SettingAn academic-based general pediatric clinic. Practice DescriptionSABA overuse is a marker of increased morbidity and mortality in children with asthma. This article describes a pharmacist-managed SABA refill telephone service. Practice InnovationThe pediatric ambulatory care pharmacy team assessed and authorized (or denied) all SABA refill requests, provided education, and facilitated appropriate follow-up using a telephone service. InterventionsUpon receiving a patient-requested SABA refill, the pharmacist identified the reason for the SABA request, assessed asthma control, and determined adherence to daily controllers or spacer use, if applicable. Education was also provided. Data obtained were used to determine SABA refill approval. EvaluationPrimary reasons for SABA refill request were for (1) current symptom management and (2) no refills remaining in the absence of symptoms. Forty-two (50%) SABA refill requests were eligible for refill per the clinic algorithm, yet 70% actually received a refill after assessment by the pharmacist. Asthma control was assessed as 26% well controlled, 38% not well controlled, and 36% very poorly controlled. Forty-eight percent of patients prescribed daily controller medications were deemed adherent. Spacers were used in 43 of 76 (56%) patients using metered dose inhalers. Education was provided to 82% of caregivers. Pharmacists facilitated asthma follow-up visits in 41 of 84 (49%) patients contacted, and 61% of those appointments were kept. ConclusionsPharmacist management of a SABA refill telephone service provides an additional means for delivery of asthma education, facilitates follow-up asthma care, helps to identify patients at risk for increased morbidity and mortality due to the overuse of SABAs, and provides another mechanism for medication refills.

Effect of frequency of clinic visits and medication pick-up on antiretroviral treatment outcomes: a systematic literature review and meta-analysis.

Introduction: Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes. Methods: As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta‐analyses were conducted. Results and discussion: Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21–2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick‐ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62–6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable. Conclusions: Our systematic review suggests that reduction of clinical visits (and likely ARVs pick‐ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.

Dispensing medication refills without counselling.

Purpose The purpose of this paper is to assess the safety and efficiency of, and acceptance by, patients for an express refill service (ERS). Design/methodology/approach A pilot uncontrolled, cross-sectional, single-centred study was conducted at the outpatient pharmacy of a tertiary acute care hospital. Under ERS, prescriptions were dispensed without clinical review and counselling for patients refilling prescription medications. Efficiency was assessed by comparing processing times of ERS prescriptions with regular prescriptions. Safety was assessed by independent review of prescriptions by two pharmacists. Patient acceptance was assessed by a survey. Findings ERS reduced processing time of prescriptions by more than 30 per cent compared to the regular fill process. ERS was generally safe for patients, with drug-related problems identified in only one prescription which may have warranted closer monitoring. It was accepted by patients who opted for the service, as 91.4 per cent agreed or strongly agreed that they were satisfied with the service. Research limitations/implications The study was conducted on a small convenience sample of patients in a single centre, with no control group. Practical implications Results showed that ERS was efficient, safe and well-accepted for select patients refilling their prescriptions. This leads to shorter waiting times and greater patient satisfaction. Originality/value This is the first published study that has explored the feasibility of an express prescription refill service. Despite some limitations, this study showed that omitting prospective clinical review and patient counselling for a defined population segment is safe, and can reduce processing time and improve patient satisfaction.

Mobile phone use for a social strategy to improve antiretroviral refill experience at a low-resource HIV clinic: patient responses from Nigeria

ABSTRACTIn sub-Saharan African areas where antiretroviral (ARV) drugs are not available through community pharmacies, clinic-based pharmacies are often the primary source of ARV drug refills. Social pressure is mounting on treatment providers to adjust ARV refill services towards user-friendly approaches which prioritize patients’ convenience and engage their resourcefulness. By this demand, patients may be signalling dissatisfaction with the current provider-led model of monthly visits to facility-based pharmacies for ARV refill. Mobile phones are increasingly popular in sub-Saharan Africa, and have been used to support ARV treatment goals in this setting. A patient-centred response to on-going social pressure requires treatment providers to view ARV refill activities through the eyes of patients who are negotiating the challenges of day-to-day life while contemplating their next refill appointment. Using focus groups of five categories of adult patients receiving combination ARV therapy, we conducted this cross-sectional qualitative study to provide insight into modifiable gaps between patients’ expectations and experiences of the use of mobile phones in facility-based ARV refill service at a public HIV clinic in Nigeria. A notable finding was patients’ preference for harnessing informal social support (through intermediaries with mobile phones) to maintain adherence to ARV refill appointments when they could not present in person. This evolving social support strategy also has the potential to enhance defaulter tracking. Our study findings may inform the development of ARV refill strategies and the design of future qualitative studies on client–provider communication by mobile phones in under-resourced HIV treatment programmes.

Using an Electronic Medication Refill System to Improve Provider Productivity in an Accountable Care Setting.

Even within fully integrated health care systems, primary care providers (PCPs) often lack support for medication management. Because challenges with conducting medication reconciliation, improving adherence, and achieving optimal patient outcomes continue to be prevalent nationally, it is critical that PCPs are provided the resources and support they need to provide high-quality, patient-centered care in an accountable care environment. Sharp Rees-Stealy Medical Group uses a fully electronic medication refill system that allows for a centralized team to manage all incoming requests. Over time, 16 disease-specific protocols were created that allowed the pharmacy team to absorb approximately 80% of incoming refill requests for all enrolled PCPs. The refill clinic assessed all clinic information that a PCP would normally review in order to approve a refill. Tasks performed by the clinical pharmacists included medication reconciliation, dosage adjustment, and coordination of distribution from external mail order and retail pharmacies. In 2014, the number of tasks related to refill management reviewed by the refill/medication therapy management service totaled 302,592, resulting in 140,350 refill authorizations and multiple interventions related to medication use. Physicians have estimated that the service provides between 20 and 30 minutes of time savings per day. Assuming an annual PCP salary of around $200,000, 20 to 30 minutes per day would amount to $33 to $50 saved per day per physician. The savings is even higher when time savings from other clinical staff is included. The development of this electronic medication refill service has provided the following important lessons: (a) organizations rely on a leader or champion to push through process reforms--this program started with reluctant physicians first to determine best practices; (b) the lack of clinical pharmacist profiles within electronic health records (EHR) is a serious concern, since the creation of these profiles may not be easy or timely; and (c) PCPs working within an EHR environment will quickly embrace the idea of a service that can save them up to 30 minutes per day. With PCPs continuing to take on additional population health management tasks in accountable care organizations, pharmacists can provide workload offsets by meaningfully contributing to medication-related care.

Capsule Commentary on Moreno et al., Disparities in the Use of Internet and Telephone Medication Refills Among Linguistically Diverse Patients.

M oreno et al. 1 examine the relationship between English proficiency and use of remote medication refill systems (that is, requesting to refill medications through automated phone or online systems rather than in person). They find that only 46 % of limited English proficient (LEP) patients with chronic illness use these services, compared to 83 % of English proficient patients. This discrepancy is not surprising, given that the majority of healthcare systems in the US offer these refill services only in English. The differences between English proficient and LEP patients weremore pronounced for online refilling than telephone refilling, which may indicate unique barriers to online portal use among this patient subgroup. Overall, this work is consistent with growing evidence that patients with communication barriers are less likely to be able to access a variety of healthcare tools (particularly online tools) that are often designed and implemented for the mainstream patient population. The study also supports the longstanding hypothesis of the Binverse care law,^ which states that the most well resourced individuals are the first to gain from the introduction of a new technology or service. The inverse care law is most problematic in exacerbating existing health/health care disparities when the technology confers a direct health benefit.We should be concerned about this issue because there is evidence that patients who use both telephone and online refilling systems have significantly improved medication adherence (a health behavior that is clinically important, but often difficult to influence). There is much more work to be done in this area. In particular, we need more research on why these barriers exist and how to overcome them. Technology offers a seemingly streamlined and efficient way to provide services tailored to the needs and preferences of the target group. Moreover, online patient portals are becoming a new standard for patient communication in health care; we will continue to offer more and more healthcare services through these websites to improve efficiency of care. Therefore, it is critical to focus on accessibility and usability upfront and guarantee that these services are available in languages other than English. If our bank ATMs can ask and remember our preferred language, isn’t it time for our health care system to design communication technologies that do the same?

An Internet-based Controlled Trial Aimed to Improve Osteoporosis Prevention among Chronic Glucocorticoid Users

To address the low prevention and treatment rates for those at risk of glucocorticoid-induced osteoporosis (GIOP), we evaluated the influence of a direct-to-patient, Internet-based educational video intervention using "storytelling" on rates of antiosteoporosis medication use among chronic glucocorticoid users who were members of an online pharmacy refill service. We identified members who refilled ≥ 5 mg/day of prednisone (or equivalent) for 90 contiguous days and had no GIOP therapy for ≥ 12 months. Using patient stories, we developed an online video addressing risk factors and treatment options, and delivered it to members refilling a glucocorticoid prescription. The intervention consisted of two 45-day "Video ON" periods, during which the video automatically appeared at the time of refill, and two 45-day "Video OFF" periods, during which there was no video. Members could also "self-initiate" watching the video by going to the video link. We used an interrupted time series design to evaluate the effectiveness of this intervention on GIOP prescription therapies over 6 months. Among 3017 members (64.8%) exposed to the intervention, 59% had measurable video viewing time, of which 3% "self-initiated" the video. The GIOP prescription rate in the "Video ON" group was 2.9% versus 2.7% for the "Video OFF" group. There was a nonsignificant trend toward greater GIOP prescription in members who self-initiated the video versus automated viewing (5.7% vs 2.9%, p = 0.1). Among adults at high risk of GIOP, prescription rates were not significantly affected by an online educational video presented at the time of glucocorticoid refill. ClinicalTrials.gov Identifier: NCT01378689.

Factors affecting medication adherence: patient perspectives from five veterans affairs facilities.

BackgroundIn the United States, more than 25 million people have diabetes. Medication adherence is known to be important for disease control. However, factors that consistently predict medication adherence are unclear and the literature lacks patient perspectives on how health care systems affect adherence to oral hypoglycemic agents (OHAs). This study explored facilitators and barriers to OHA adherence by obtaining the perspectives of Veterans Affairs (VA) patients with OHA prescriptions.MethodsA total of 45 patients participated in 12 focus groups that explored a wide range of issues that might affect medication adherence. Participants were patients at clinics in Seattle, Washington; San Antonio, Texas; Portland, Oregon; Salem, Oregon, and Warrenton, Oregon.ResultsKey system-level facilitators of OHA adherence included good overall pharmacy service and several specific mechanisms for ordering and delivering medications (automated phone refill service, Web-based prescription ordering), as well as providing pillboxes and printed lists of current medications to patients. Barriers mirrored many of the facilitators. Poor pharmacy service quality and difficulty coordinating multiple prescriptions emerged as key barriers.ConclusionsVA patient focus groups provided insights on how care delivery systems can encourage diabetes medication adherence by minimizing the barriers and enhancing the facilitators at both the patient and system levels. Major system-level factors that facilitated adherence were overall pharmacy service quality, availability of multiple systems for reordering medications, having a person to call when questions arose, counseling about the importance of adherence and providing tools such as pillboxes and updated medication lists.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0533-1) contains supplementary material, which is available to authorized users.

C-A4-02: Do Automated Phone Calls Improve Adherence to Inhaled Corticosteroids (ICS)?

Rationale: Adherence to ICS among individuals with asthma is poor and associated with increased asthma symptoms and acute health care utilization; diminished quality of life; and increased health care costs. Objective: To determine if a brief, automated telephone intervention using speech recognition (SR) technology improves ICS adherence among adults with asthma. Methods: PEANUT is an ongoing randomized clinical trial involving 14,064 members of a health maintenance organization (HMO), aged >18 years, taking medication for the management of asthma. Participants receive usual care (UC) or an 18-month SR intervention. SR participants receive monthly refill reminder calls, as needed, based on dispensing data derived from the electronic medical record. The calls provide educational information, explore barriers to adherence, and offer transfer to an automated refill line as appropriate. The primary outcome is the continuous measure of medication adherence (CMA), a measure of medication days dispensed relative to total observation days. Preliminary data through the first 8 months are presented. Results: Of over 10,000 calls attempted so far, we successfully reached the target participant 45% of the time and left a voice message on an additional 40% of calls. CMA scores are significantly higher for SR than UC participants (0.48 vs. 0.45, P 60 yrs. One in 16 calls results in a direct transfer to the HMO’s automated prescription refill service. Conclusion: Early results suggest a small, significant intervention effect. Because small changes in adherence on a population basis can have important public health benefits, this study supports the potential value of SR-based adherence interventions for asthma and other chronic diseases.

Early Experiences with e-Health Services (1999–2002)

E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use. The objective of this study was to examine trends in e-health use and user characteristics. This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services. Approximately 3.3 million members of a large, prepaid IDS. Amount and frequency of e-health use over time and characteristics of users. The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types. Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services.

Identifying and Assisting Low-Literacy Patients with Medication Use: A Survey of Community Pharmacies

Nearly one-half of adult Americans have limited functional literacy skills. Low patient literacy is associated with poor medication adherence and health outcomes. However, little is known about how pharmacies address literacy-related needs among patrons. To determine the frequency with which pharmacies identify and provide appropriate assistance to patients with limited literacy skills and provide specific recommendations to help improve pharmacists' recognition of low health literacy, as well as strategies to improve adherence in this population. Through a telephone-based survey of Atlanta-area pharmacies, we obtained information on (1) whether the pharmacy attempted to identify patients with limited literacy skills, (2) what measures were taken by the pharmacy to optimize the health care of low-literacy patients, especially with regard to medication adherence, and (3) what services the pharmacy offered to improve adherence in general. The response rate among eligible pharmacies was 96.8% (N = 30). Only 2 (7%) pharmacies reported attempting to identify literacy-related needs among their patrons. One of these facilities provided additional verbal counseling to assist low-literacy patients, and the other pharmacy involved family members, provided verbal counseling, and had patients repeat instructions to confirm comprehension. Most pharmacies reported availability of adherence aids that could help low-literacy patients if such patients were identified and targeted to receive additional assistance. These included verbal and written counseling (offered at 73% of pharmacies), packaging or organizing aids (27%), refill services (17%), and graphic or multimedia aids (13%). Pharmacies infrequently attempt to identify and assist patients with limited literacy skills.