Heidi R. Luder

U.S. emergency departments visits resulting from poor medication adherence: 2005–07

OBJECTIVES To describe characteristics and trends for emergency department visits related to medication nonadherence and to identify associations between patient characteristics and emergency department visits related to medication nonadherence. DESIGN Retrospective cross-sectional study. SETTING National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 to 2007. PATIENTS Patients who had an emergency department visit for medication nonadherence. INTERVENTION NHAMCS data were weighted to yield national estimates of emergency department visits related to medication nonadherence. Descriptive frequencies were calculated for visits related and unrelated to medication adherence. A binary logistic regression model was used to identify covariates for nonadherence. MAIN OUTCOME MEASURES National estimates of emergency department visits related to medication nonadherence. RESULTS An estimated 456,209 ± 68,940 (mean ± SD) nonadherence-related visits occurred. Of visits related to nonadherence, 29% resulted from mental health disorders. Significant covariates of nonadherence-related visits included age, payment source, and primary diagnosis. Visits for patients with mental illness (odds ratio 22.74 [95% CI 14.68-34.20]), type 2 diabetes (15.80 [5.20-48.06]), nondependent abuse of drugs (11.85 [3.83-36.65]), or essential hypertension (11.06 [3.99-30.61]) were significantly associated with the probability that an emergency department visit was related to nonadherence. More than 20% of emergency department visits related to medication nonadherence resulted in hospital admission, whereas only 12.7% of visits unrelated to nonadherence resulted in hospital admission ( P < 0.0001). CONCLUSION Medication nonadherence is an important problem. Targeting patients at high risk for nonadherence, especially patients with mental illness, may improve medication adherence and prevent future emergency department visits.

Pediatric asthma medication therapy management through community pharmacy and primary care collaboration

OBJECTIVES To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy. SETTING Underserved inner city of Cincinnati, OH. PRACTICE DESCRIPTION A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Childrens Hospital Medical Centers (CCHMC) 3 pediatric primary care centers. PRACTICE INNOVATION Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations. EVALUATION Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures. RESULTS Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively. CONCLUSION This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives.

Health Beliefs Describing Patients Enrolling in Community Pharmacy Disease Management Programs

Objectives: The purpose of this study was to survey new enrollees in a community pharmacy, employer-based diabetes and hypertension coaching program to describe the characteristics, health beliefs, and cues to action of newly enrolled participants. Methods: A 70-question, 5-point Likert-type survey was developed using constructs from the Health Belief Model (HBM), Theory of Planned Behavior (TPB), and Theory of Reasoned Action (TRA). New enrollees in the coaching programs completed the survey. Survey responses between controlled and uncontrolled patients and patient demographics were compared. Results: Between November 2011 and November 2012, 154 patients completed the survey. Patients were fairly well controlled with a mean hemoglobin A1C of 7.3% and a mean blood pressure of 134/82 mm Hg. The strongest cue to action for enrollment was the financial incentives offered by the employer (mean: 3.33, median: 4). White patients were significantly more motivated by financial incentives. More patients indicated they had not enrolled previously in the program because they were unaware it was available (mean: 2.89, median 3.0) and these patients were more likely to have an uncontrolled condition (P ≤ 0.050). Conclusion: A top factor motivating patients to enroll in a disease management coaching program was the receipt of financial incentives. Significant differences in HBM, TPB, and TRA responses were seen for patients with different demographics.

Clinical outcomes of switching from insulin glargine to NPH insulin in indigent patients at a charitable pharmacy: The Charitable Insulin NPH: Care for the Indigent study

OBJECTIVES To assess the clinical outcomes of indigent patients with type 2 diabetes served by a charitable pharmacy after therapy change from insulin glargine to NPH insulin. DESIGN This was a 24-week prospective pilot study. SETTING Community charitable pharmacy. PARTICIPANTS Underserved, financially disadvantaged adults with type 2 diabetes. INTERVENTION Conversion from insulin glargine to NPH insulin. MAIN OUTCOME MEASURES HbA1c, 30-day average blood glucose, number of suspected and confirmed hypoglycemic episodes, total insulin dose, and Morisky Medication Adherence Scale (MMAS) scores. RESULTS Patients in both control and intervention groups improved in disease-state clinical markers, safety profile, and total insulin dose. MMAS scores were unchanged. CONCLUSION There were no statistically significant differences in glycemic control or hypoglycemic episodes between the control (NPH insulin) or intervention group (insulin glargine to NPH insulin).

Poverty, Transportation Access, and Medication Nonadherence

PMN varies significantly across 1 metropolitan area. Pharmacies can be key collaborators within communities focused on improving population health. BACKGROUND AND OBJECTIVES: Variability in primary medication nonadherence (PMN), or failure to fill a new prescription, influences disparities and widens equity gaps. This study sought to evaluate PMN across 1 metropolitan area and assess relationships with underlying zip code–level measures. METHODS: This was a retrospective observational study using data extracted from 1 regional community pharmacy market-share leader (October 2016–April 2017). Data included patient age, sex, payer, medication type, and home zip code. This zip code was connected to US census measures enumerating poverty and vehicle access, which were treated as continuous variables and within quintiles. The prescription-level outcome was whether prescriptions were not filled within 30 days of reaching the pharmacy. The ecological-level outcome was PMN calculated for each zip code (numerator, unfilled prescriptions; denominator, received prescriptions). RESULTS: There were 213 719 prescriptions received by 54 included pharmacies; 12.2% were unfilled. Older children, boys, and those with public insurance were more likely to have prescriptions not filled. Prescriptions originating from the highest poverty quintile were significantly more likely to not be filled than those from the lowest poverty quintile (adjusted odds ratio 1.60; 95% confidence interval 1.52–1.69); a similar pattern was noted for vehicle access (adjusted odds ratio 1.77; 95% confidence interval 1.68–1.87). At the ecological level, there were significant, graded relationships between PMN rates and poverty and vehicle access (both P < .0001); these gradients extended across all medication classes. CONCLUSIONS: Poverty and vehicle access are related to significant differences in prescription- and ecological-level PMN across 1 metropolitan area. Pharmacists and pharmacies can be key partners in population health efforts.

Community pharmacist collaboration with a patient-centered medical home: Establishment of a patient-centered medical neighborhood and payment model

OBJECTIVES To determine the feasibility of a partnership between a community pharmacy and a patient-centered medical home (PCMH) by measuring the impact on office- and patient-level clinical outcomes. SETTING Kroger Pharmacy and a PCMH practice in Cincinnati, OH. PRACTICE DESCRIPTION The Kroger Co. is a large grocery store chain that operates 102 pharmacies in the Cincinnati-Dayton marketing area. The PCMH practice is an accredited PCMH office serving more than 9000 patients in the Cincinnati area. PRACTICE INNOVATION In a medical neighborhood, a PCMH coordinates care with other local specialty practices or partners. A partnership between the community pharmacy chain and the PCMH was established to create a medical neighborhood. The pharmacist spent 2 half-days per week at the PCMH. The pharmacist provided initial medication therapy management appointments in the PCMH and offered follow-up services in the office, the pharmacy, or both, depending on patient preference. The pharmacy received a capitated payment per patient per month for a predetermined number of 1000 high-risk patients. MAIN OUTCOME MEASURES Office-level changes in clinical outcomes such as A1C, blood pressure, and lipid measures were collected and compared with those of a similar control office. In addition, patient-level outcomes such as change in A1C, blood pressure, lipids, and weight were measured. RESULTS One hundred five patients were seen by the pharmacist during the study period, with 1.5% of the total managed at the office. There was a statistically significant increase in influenza vaccinations received. On a patient level, A1C and systolic blood pressure significantly improved. CONCLUSION This project represents an exciting opportunity for community pharmacists to expand their scope of services through direct partnership with PCMHs and maintain a sustainable reimbursement structure.

Impact of the pay-for- performance-for-patients program for diabetes management

OBJECTIVES To determine whether patients with diabetes who used a financial rewards program in a grocery chain pharmacy had increased rates of self-reported healthy behaviors, to measure the impact of the program on glycosylated hemoglobin (A1C), and to measure the impact of the program on grocery store sales. METHODS This prospective study took place at one location of a grocery chain pharmacy in Cincinnati, OH. Adult patients with diabetes on at least one diabetes medication were eligible to participate. Participants received a

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate.

5 incentive for each weeklong behavior log completed and reviewed with the pharmacist, who provided counseling on improving healthy behaviors. Change in self-reported healthy behaviors, A1C, grocery store expenditure, and program satisfaction were measured. RESULTS During the 12-week study, 25 patients enrolled in the program. A total of 13 participants completed the poststudy survey and reported increased rates of self-monitoring of blood glucose and blood pressure and increased exercise frequency. Differences in A1C and grocery store expenditures were unable to be detected. Satisfaction with the pay-for-performance-for-patients (P4P4P) program was favorable (8.6 on a 10-point scale). CONCLUSION Participants given small, frequent financial incentives had increased frequency of healthy behaviors and were satisfied with the P4P4P program.