Community pharmacists can bend medication adherence curve


Walgreens explores use of predictive models and risk stratification


Medication adherence continues to be a challenge for patients, particularly those who are new to therapy with diseases that are asymptomatic and who may not feel as if they need medication.

In a recent study published in the Journal of Managed Care Pharmacy (, patients who were new to therapy and were being treated for one of six chronic conditions refilled their medications only approximately 18% to 54% of the time over a 12-month period.

The cost of nonadherence to the U.S. healthcare system has been estimated at $290 billion, according to research published in 2009 by the New England Health Institute.

Predict and intervene

Community pharmacy programs can help to bend the medication adherence curve using predictive modeling and risk stratification, as well as product-specific interventions, said Walgreens experts at the World Congress Summit in Philadelphia.

Kristi Rudkin, PharmD, senior director of product development for Walgreens, and Michael S. Taitel, PhD, Walgreens senior director of clinical outcomes and analytic services, shared the findings of their research into what will help patients better manage their conditions and stay adherent to their medications.

“Medication adherence is a challenge. The same patient can have multiple barriers to the same medication over time, so it is difficult to pinpoint one solution,” said Rudkin in an interview with Drug Topics.

The WAG approach

Walgreens is developing a predictive model for medication adherence and using risk stratification to identify patients who may need extra help with medication adherence. It is also using these tools to target those new to therapy based on their risk profiles, said Taitel.

Patients fall into two categories: those who are new to therapy and new to Walgreens, and existing patients who are new to therapy. Examination of existing patients’ previous adherence to other therapies makes it easier to predict which ones need intervention to support medication adherence.

“For those who are new to Walgreens, we can rely on the characteristic of the drug and the characteristics of the prescriber, but probably more importantly we look at census tract data - the neighborhood and the patient’s health insurance copayment amounts,” Taitel said. “So cost is a predictor and can be a barrier for many people, but it is not the No. 1 barrier. The No. 1 barrier is forgetfulness.”

Other reasons that contribute to adherence rates among new-to-therapy patients who refill late include side effects, doubts about the need for medication, regimen complexity, and miscellaneous barriers, Taitel said.

Face-to-face: Statins

In a retrospective cohort study that included 76 community pharmacies in the Midwest, pharmacist-led face-to-face counseling helped improve medication adherence for patients who were new to statin therapy and were followed for 12 months, Taitel said.

Patients considered to be adherent had a medication possession ratio (MPR) of at least 80%. There were 586 patients who participated in two face-to-face counseling sessions with a pharmacist and 516 who received usual care. At 12 months, there was a 7.2% difference in individuals in the intervention group who were adherent (40.9% with an MPR ≥80%) compared to those in the control group (33.7% with an MPR ≥80%).

“This represents a 21% improvement,” Taitel said. “This is a piece of the answer, making sure those patients who are new to therapy get a good start. They know they can rely on another healthcare professional, their pharmacist.”

Face-to-face: Injections

Face-to-face counseling also made a difference for patients who were new to therapy injections. By coaching about where and when to inject; setting expectations about possible side effects, such as nausea; and ensuring patients have needles at the outset of therapy, pharmacists can have an impact on medication adherence. In a research study supported by a pharmaceutical manufacturer, patients were coached at the first refill to determine how comfortable they were with self-injections, and side effects were assessed. More than 40,000 patients were randomized to the face-to-face counseling and coaching, and approximately 4,600 were in the control group.

“Part of the issue with side effects is the unexpected,” he said. “If patients know that a particular side effect is common and expect it, then they will be able to get through it. Setting up expectations is important.”

The persistency curve showed a positive result 270 days after the first refill, with 40% of patients who had been coached still on treatment compared with only 37% who had not been coached about injection training.

‘Test patients had 8.4% more days of therapy,” Taitel said. “From the beginning, we are keeping patients more adherent, and they are staying more adherent and not returning to the baseline.”

Refill reminders

The automated telephone reminders, also known as automated refill reminders (ARR), also helped move the adherence rate for patients who were on maintenance medications for chronic conditions.

“The goal of ARR was to help patients remember to refill their prescriptions,” said Rudkin. “Based on the last sold prescription, Walgreens will estimate when they are due for a refill and three days before that the pharmacy will make an automated refill call. Patients can automatically refill without having to enter the script number, and it also serves as a reminder that they are due for a refill.”

The persistence for the intervention group was 7.8 days longer than for the control group, which was followed for almost 1 year. The intervention group included 151,418 scripts; the control group had 327,975 scripts. The MPR was 67.3% in the intervention group and 64.9% in the control group.

“From our research and others, the refill reminders are an important piece to the adherence challenge,” Taitel said. “It is one of the many interventions that need to occur to help patients be adherent. It is a reminder for those who need it the most."

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