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Specialty Pharmacy Improves Adherence to Imatinib

Published Online: December 05, 2013
Jay Visaria, PhD, MPH; Rochelle Henderson, PhD, MPA; and Sharon Glave Frazee, PhD, MPH
Background: Adherence to imatinib contributes to treatment success in patients with chronic myeloid leukemia. Specialty pharmacies offering refill reminders, care management, and educational
programs may improve adherence to imatinib.

Objectives: To compare adherence to imatinib between patients using a specialty pharmacy (specialty pharmacy group) and patients using other dispensing channels (other pharmacy group).

Study Design: Retrospective, pharmacy claims–based observational study using pharmacy benefits manager data from 2010 to 2012.

Methods: Patients starting a new course of imatinib therapy we followed for 365 days after treatment initiation. Medicare and Medicaid benefi ciaries and patients who paid 100% of the cost of imatinib out of pocket were excluded. Optimum imatinib adherence was defined as a proportion of days covered of 90% or higher. Multivariate logistic regression was used to evaluate the impact of dispensing channel on medication adherence, controlling for differences in demographics, medication burden, out-of-pocket spending per 30-day adjusted imatinib prescription, average days of supply per imatinib prescription, and use of a prescription days-of-supply optimization program.

Results: The final study sample consisted of 704 patients, 433 in the specialty pharmacy group and 271 in the other pharmacy group. After multivariate adjustment, patients in the specialty pharmacy group had 1.46 times greater odds of attaining optimum adherence to imatinib compared with patients in the other pharmacy group (95% confi dence interval, 1.02-2.09).

Conclusion: Patients who used a specialty pharmacy offering refi ll reminders, care management, and educational programs achieved higher rates of optimal adherence to imatinib compared with those using other dispensing channels.

Am J Pharm Benefits. 2013;5(Special Issue):SP33-SP39
Chronic myeloid leukemia, also called chronic myelogenous leukemia (CML), is a slow-growing cancer of the white blood (myeloid) cells in bone marrow and blood. It is estimated that there will be 5920 new cases of CML and 610 deaths due to CML in the United States in 2013. The incidence of CML increases with age, with half of all new cases of CML diagnosed in individuals 65 years or older.1 As record numbers of American baby boomers (born between 1946 and 1964) reach their mid-60s, the number of new patients diagnosed with CML is expected to increase.2

Untreated, CML takes an average of 4 years to become more aggressive and reach the blastic stage, when it is usually fatal. However, the prognosis and survival of CML patients have improved dramatically since imatinib, an orally administered chemotherapeutic agent, was approved by the US Food and Drug Administration in 2001. Five-year survival rates for newly diagnosed patients with CML increased from 40% between 1996 and 2000 to more than 55% between 2001 and 2007.3 Long-term studies have shown dramatically decreased mortality and improved survival among CML patients taking imatinib.4,5 Consequently, CML has effectively been transformed into a chronic disease with patients using imatinib and other CML medications over extended periods of time.6 Despite imatinib’s life-extending benefits, many patients struggle to remain adherent to it. A large body of scientific evidence has demonstrated that optimum outcomes from drug therapy are reliant on adherence.7 Although previously published studies have defi ned optimum adherence to imatinib as 90% or above, actual average adherence among US commercially insured CML patients is reported at about 80%,8,9 with only 54% of patients taking imatinib achieving adherence of 90% or higher.9

CML patients face many challenges influencing their medication adherence, including coordination with physicians and other healthcare providers, managing complex treatment regimens, medication side effects, and healthcare costs. Common side effects of imatinib include diarrhea, muscle cramps, nausea, skin reactions, swelling, and vomiting. More serious adverse effects such as myelosuppression (decreased ability of bone marrow to produce blood cells) and elevated liver transaminase levels (indicative of liver damage) may require treatment interruptions.10 Additionally, with the annual cost of therapy reported to be $92,000 in 2012, the economic burden of imatinib is substantial.11 Couple the clinical challenges with the out-of-pocket drug cost facing cancer patients, and it is not surprising that medication adherence is lower than desired, posing a serious concern to patients, clinicians, and payers.

The need to improve medication adherence among patients using oral oncology medications such as imatinib is widely recognized.12,13 According to a National Comprehensive Cancer Center Task Force, oncology-specific support from specialty pharmacies improves adherence, encourages communication between patients and pharmacists, identifies potential safety concerns, helps prevent unwarranted drug expenditures, and ensures appropriate use of medications.14 Given the suboptimal adherence rates to imatinib therapy, patients given this medication, especially those who are new to imatinib therapy,15 are ideal candidates for therapy-related services commonly provided by specialty pharmacies such as refill reminder programs and oncology care management.12,16

Our hypothesis was that adherence to imatinib would be higher among patients starting a new course of therapy with a specialty pharmacy instead of other dispensing channels. Our study objective was to compare imatinib adherence between patients using specialty pharmacy and those using other dispensing channels.

METHODS

A claims-based, retrospective study was conducted using de-identified prescription data collected by a large national pharmacy benefi ts manager (PBM) with an in-house specialty pharmacy. Patients receiving imatinib through the specialty pharmacy had access to supportive services designed to enhance clinical outcomes, increase drug safety, manage side effects, and help patients stay on therapy. Nurses and pharmacists specifically trained in oncology provided education and care management through proactive patient outreach throughout the course of therapy at clinically meaningful intervals. Telephonic prescription refill reminders were timed to be made when the patient’s quantity of imatinib reached a specifi ed level prior to depletion, to ensure an uninterrupted supply of medication.

Research Design

Pharmacy claims data for the period July 1, 2010, to August 31, 2012, were analyzed. Irrespective of the type of pharmacy or dispensing channel used, the claims data set included all patients for whom the PBM processed claims for oncology drugs. Thus, patients in the study could obtain imatinib from any combination of the inhouse specialty pharmacy, other specialty pharmacies, retail pharmacies, or home delivery pharmacies. Patients who obtained a simple majority of their 30-day adjusted imatinib prescriptions from the PBM’s in-house specialty pharmacy were assigned to the specialty pharmacy group. Patients receiving a majority of their imatinib supply from other channels were assigned to the other pharmacy group. The design of this study was not submitted to an institutional review board, as only de-identified administrative data were used. All regulations related to the Health Insurance Portability and Accountability Act were followed.17

Study Population

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Issue: Specialty Pharmacy
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