Improving Medication Adherence through Workplace Primary Care and Pharmacy

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Improving Medication Adherence through Workplace
Primary Care and Pharmacy

• Bruce Sherman, MD, FCCP
• Medical Director
• The Goodyear Tire Rubber Company

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Todays discussion

• Medication adherence, compliance, and persistence
  - definitions
• Healthcare cost impact of poor adherence
• Reasons for poor adherence and approaches to
  improvement
• Role of worksite medical clinics and pharmacy in
  improving medication adherence

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The language of medication adherence

• Compliance how well a patient follows physician
  orders within a designated timeframe
• Adherence same as compliance
• Persistence how long a patient remains on
  therapy after starting
• Medication Possession Ratio (MPR) the total
  days supply of medication obtained during the
  period of persistence, divided by the
  corresponding number of calendar days
  (non-adherence is defined as an MPR of lt 80).

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Medication adherence hyperlipidemia treatment
Compliance by medication class reveals greater
adherence variability
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Persistency of medication use statins

• Key points
• 30 of statin users have lt80 adherence
• Of new users, 20 stop statin medication after
  first prescription

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Lower medication adherence results in higher
overall healthcare costs
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Economic impact of poor medication adherence

• Only about 50 percent of American patients
  typically take their medicines as prescribed,
  resulting in approximately 100 billion in annual
  direct costs
• An estimated 10 of hospitalizations are
  attributable to poor adherence
• Not taking medicines as prescribed has been
  associated with as many as 40 percent of
  admissions to nursing homes
• Additional 2,000 a year per patient in medical
  costs for visits to physicians' offices.

National Council on Patient Information and
Education, 2007
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Multiple contributors to poor adherence

• Cost
• Understanding of condition
• Provider relationship
• Provider continuity
• Provider follow-up
• Medication dosing schedule
• Comorbid conditions and other medications
• Side effects
• Perceived benefit from medication
• Self-efficacy
• Motivation

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Lower co-pays can improve clinical outcomes and
reduce costs

157 patients were eligible for both the economic
and clinical cohorts 18,000 is equivalent to
the salary of 1 FTE for the employer within which
the analysis was completed
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Patient-centered solutions

• Med-eMonitor System
• Interactive patient medication dispensing device
• Automated reminders
• Networked to track adherence
• Demonstrated clinical outcomes Medicare
  population
• Adherence increased from 40 to 92 for diabetes
• HbA1C levels declined by 18 in 3 months
• ? Applicability to workforce

InforMedix Medication Adherence Solution
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Patient-centered solutions
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Focus on statins Research results to improve
adherence
Intervention Adherence outcome Clinical outcome
Peterson, 2004 Informational monthly pharmacist home visits for 6 mos., incl. med/lifestyle issues, point of care testing, vs. usual care Self-reported No change Lipid profile No change
Marquez-Contreras, 2004 Behavioral 3 phone calls during 6 mos to evaluate adherence, provide tailored recommendations vs. usual care for hyperlipidemia. Levels at 3 and 6 months 93.0 study 84.4 control Study 44 to target control 23.1 to target
Coull, 2004 Monthly informational/support group meetings by lay health mentors vs. usual care for heart disease patients Study group gt60 years old Significant improvement (plt.01) No change in total events/12 months
Straka, 2005 Pharmacist education and management in clinic setting vs. usual care for hyperlipidemia Not provided 72 to target control 18 to target. 18 month F/U study 65 to target control 46 to target
Lapointe, 2006 4 month telephone management vs. usual care after MI until target levels achieved. Follow up at 12 and 18 months in both groups to evaluate compliance/efficacy More than 90 adherent in both groups Study 23.4 to target control 38.3 to target
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Interventions and their potential impact on
barriers to medication adherence
Effective focus of intervention Effective focus of intervention Effective focus of intervention Effective focus of intervention Effective focus of intervention
Barriers Intervention Employee cost Access to services Patient education Provider continuity Treatment to target
Pharmacist educator (X) (X) X X (X)
Disease mgmt/adherence program (X) X (X) (X)
Web/phone-based reminder X
Provider training (X) X X
Pay for performance (X) X
At-home reminder tools (X)
Half-tablet program X
Co-pay waiver X
Mandatory mail order X (X)
Concierge service (X) X
On-site pharmacy and clinic X X X X X
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A multidisciplinary approach is likely a more
effective solution

• Integrate
• cost incentives
• improved access
• patient education/empowerment
• quality management
• Worksite clinic/pharmacy incorporates these
  components
• Demonstrable results

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On-site clinic and pharmacy

• Key attributes
• Improved patient access
• Integrated service delivery
• Reimbursement model isnt driven by CPT billing
  or volume
• Enhanced attention to preventive care and chronic
  condition management
• Integrated tracking of prescription adherence
  with provider reports

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On-site medical and pharmacy use increases
medication adherence
CHD Meridian/Goodyear
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Integrated worksite care favorable adherence
shift to higher quintiles
Adherence Profile for Diabetics Taking Insulin
CHD Meridian/Goodyear
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Summary

• Patient, provider and health system all
  contributors to suboptimal medication adherence
• Treatment to target a major additional
  consideration
• Multidisciplinary interventions are likely to be
  most effective
• Worksite pharmacy/clinic model promotes adherence
  and treatment to target goals