Pharmacists enlisted to make sure patients stick with prescriptions



The number of Americans with a chronic disease that requires at least one medication, such as heart disease and diabetes, is expected to grow to 157 million by 2020. As these numbers rise, so does the need to address the prevalence of medication non-adherence, which is already estimated to cost between $100 billion and $289 billion and 125,000 lives annually.

A new study from the University of Pittsburgh, named the Pennsylvania Project, used the expertise and accessibility of community pharmacists to improve medication adherence. The results, published Aug. 4 in the health policy journal Health Affairs, suggested adherence ultimately lowers health care costs through reduction of ER and hospital visits.

Non-adherence to medications is often the result of skipping refills or doses due to hefty costs, undesirable side effects, unawareness of what the medication does and avoiding medication because it interferes with lifestyle choices, like drinking alcohol.

“Pharmacists are all over the community and we have underutilized their ability to work with patients,” said Janice Pringle, the study’s lead investigator and director of program evaluation and research at Pitt’s School of Pharmacy.

“Pharmacists may be the most accessible health care professionals at any given time,” said Anne Burns, vice president of practice affairs with the American Pharmacist Association. “They train to get a doctorate of pharmacy and are uniquely positioned to see all the medications someone is taking and putting those pieces of the puzzle together to help patients in the best way possible.”

Pitt staff members conducted workshops to train 283 pharmacists to briefly screen patients, using Likert scales and surveys, and then speak with those at-risk for non-adherence using motivational interviewing techniques. The screening and brief intervention approach was implemented in 107 Rite Aid pharmacies filling 29,042 people’s prescriptions in 2011.

Through the SBI model, patients and pharmacists worked together to assess and create strategies for adherence. “Health care is moving away from a more paternalistic model where physicians or pharmacists dictate to patients what to do,” said Sam Stolpe, director of quality strategies at Pharmacy Quality Alliance. “That’s not the way we see patient-centered care now. We want patients to be empowered and take control of their health, mitigating risks for health problems. Good health care is good self-care.”

Pharmacists screened for five classes of common medications used to treat chronic conditions; oral anti-diabetic medications, medications used with high cholesterol (statins), calcium and calcium channel blockers, beta blockers and renin-angiotensin RASA.

“Reports have highlighted that the rates of medication adherence for patients with chronic conditions are very low,” said Ms. Burns. “This is an area that is costing the health system in a significant way.”

Jesse McCullough, director of field clinical services at Rite Aid Corp. who holds a doctor of pharmacy degree, said non-adherence is also due to the “silent state” of certain chronic diseases. “You may not feel like you have the symptoms all the time — you may not feel your high blood pressure all day even if you have it — so because those conditions are silent, you don’t really know if you’re OK until something bad happens.”

When something bad does happen, the price tag of a visit to the emergency room is often more expensive than the one on the script pad. “The congressional budget office did a scoring of adherence,” said Mr. Stolpe, “if you improved it by just 1 percent across 50 million Medicare patients, you can lower the cost to the federal government by $1.5 billion. That's including the medication cost.”

Non-adherence raises the risk for mortality from 12 to 25 percent in statins and 50 to 80 percent in cardioprotective medications.

To assess medication adherence, researchers calculated the proportion of days covered for the intervention year, 2011, and also 2010, to be used as a benchmark. They used a PCD of 80 percent, meaning medication was taken at least 80 percent of the expected period, the minimal dosage required to achieve the desired clinical outcome.

PCD80 rates for all five medications in the SBI group exhibited statistically significant improvements in adherence compared to 111 control pharmacies that didn’t use SBI. Annual health care costs of SBI patients dropped by $341 for those taking oral diabetes drugs and $241 for those taking statins. “Costs dropped for every member,” said Ms. Pringle, “it was largely driven by use of departments and hospitals.”

Pharmacists also had access to a monthly cloud-based report card which monitored and compared adherence of their patient population to other pharmacies in the area. “The use of these report cards is evolving in the health care system as a whole,” said Ms. Burns. “They provide the heath care provider with a summary of how the patient population is doing.”

“As an industry, pharmacies are looking at how they can improve adherence,” said Mr. McCullough, “at Rite Aid we are already doing some things based on what we learned from this study.”

“We think this could be implemented in many ways to significantly improve adherence,” said Ms. Pringle. “We should keep working from a patient perspective.”

Campbell North: cnorth@post-gazette.com or 412-263-1613.

A new University of Pittsburgh study suggests that meeting with and monitoring patients who are most likely to skip taking their medications makes it less likely they will end up in emergency rooms and can save up to $341 per person annually in health-care costs. Multiply those results by 50 million Medicare patients, and the federal government can save $1.5 billion, one funder of the study said.

The study, named the Pennsylvania Project, was published Aug. 4 in the health policy journal Health Affairs. Researchers relied on 283 pharmacists working at 271 Rite Aid pharmacies across the state, filling 29,042 people’s prescriptions in 2011. For this study, they focused on people taking the most common medications used to treat chronic conditions: oral anti-diabetic drugs, statins used to treat high cholesterol, calcium and calcium channel blockers, beta blockers, and RASA meds used to treat high blood pressure.

The number of Americans with a chronic disease that requires at least one medication, such as heart disease and diabetes, is expected to grow to 157 million by 2020. And they are the ones most likely to be guilty of non-adherence, which means skipping refills or doses due to the cost, undesirable side effects or confusion on the medication’s purpose or because it interferes with lifestyle choices, such as drinking alcohol.

Pitt decided to work with local pharmacists because they often know more about patients’ medication usage than their doctors, said Janice Pringle, the study’s lead investigator and director of program evaluation and research at Pitt’s School of Pharmacy.

“Pharmacists are all over the community and we have underutilized their ability to work with patients,” she said

Anne Burns, vice president of practice affairs with the American Pharmacist Association, agreed.

“They train to get a doctorate of pharmacy and are uniquely positioned to see all the medications someone is taking and putting those pieces of the puzzle together to help patients in the best way possible."

Pitt staff members conducted workshops to train the Rite Aid pharmacists to briefly screen patients, using Likert scales and surveys, and then speak with those at-risk for non-adherence using motivational interviewing techniques. The patients and pharmacists then worked together to come up with ways to make sure they regularly filled prescriptions and took their meds. It’s a strategy good pharmacists already follow, said Sam Stolpe, director of quality strategies at Pharmacy Quality Alliance.

”Health care is moving away from a more paternalistic model where physicians or pharmacists dictate to patients what to do. We want patients to be empowered and take control of their health, mitigating risks for health problems. Good health care is good self-care," he said.

Ms. Burns said people with chronic conditions have some of the lowest rates of medication adherence. Jesse McCullough, director of field clinical services at Rite Aid Corp., has an idea why that is .

“You may not feel like you have the symptoms all the time. You may not feel your high blood pressure all day even if you have it. Because those conditions are silent, you don’t really know if you’re OK until something bad happens.”

When something bad does happen, the patient often ends up in the emergency room.

“The congressional budget office did a scoring of adherence,” Mr. Stolpe said. “If you improved it by just 1 percent across 50 million Medicare patients, you can lower the cost to the federal government by $1.5 billion. That's including the medication cost.”

Non-adherence raises the risk for mortality from 12 to 25 percent in statins and 50 to 80 percent in cardioprotective medications according to educational material from the CDC.

Researchers considered patients as adhering to prescribed medications if they took it at least 80 percent of the time, the minimal dosage required to achieve the desired clinical outcome. When compared to a control group of 111 pharmacies that did not do intensive screening and follow-up, annual health care costs dropped by $341 for those taking oral diabetes drugs and $241 for those taking statins. Pharmacists also had access to a monthly report card which monitored and compared adherence of their patient population to other pharmacies in the area.

“As an industry, pharmacies are looking at how they can improve adherence,“ said Mr. McCullough. ”At Rite Aid, we are already doing some things based on what we learned from this study."

“We think this could be implemented in many ways to significantly improve adherence,” said Ms. Pringle. “We should keep working from a patient perspective.”


Campbell North: cnorth@post-gazette.com or 412-263-1613

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