AJMC

Dispensing Channel and Medication Adherence: Evidence Across 3 Therapy Classes

Published Online: October 22, 2013
Reethi Iyengar, PhD, MBA, MHM; Rochelle Henderson, PhD, MPA; Jay Visaria, PhD, MPH; and Sharon Glave Frazee, PhD, MPH
Objectives: To examine the association of mail order versus retail pharmacy dispensing channels with medication adherence for patients on diabetes, hypertension, or high blood cholesterol  medications, controlling for prior adherence behavior (PAB) and days of supply.

Study Design: Retrospective analysis using de-identified pharmacy claims data from a large national pharmacy benefits manager between April 2009 and December 2011.

Methods: Continuously eligible patients with an antidiabetic, antihypertensive, or antihyperlipidemic prescription claim between October and December 2009 were identified and followed over a 2-year period. Multivariate logistic regression was used to evaluate the impact of dispensing channel on medication adherence, controlling for differences in demographics, disease burden, and drug use pattern. Patients with a medication possession ratio of 80% or greater were considered adherent. The analysis controlled for PAB by using patients’ adherence status in 2010.

Results: Overall, patients using the mail order channel had higher adherence rates than their retail counterparts across all 3 therapeutic classes. In 2011, the likelihood of a mail order patient being adherent was approximately 1.15 times higher than that of a retail patient for antidiabetics, 1.11 times higher for antihypertensives, and 1.19 times higher for antihyperlipidemics. PAB was the strongest contributor to the odds of a patient being adherent across all 3 therapy classes: odds ratios ranged from 5.87 to 9.49.

Conclusions: After adjusting for PAB, differential days of supply, and differences in demographics and disease burden, patients who use mail order have a greater likelihood of being adherent than patients who use a retail pharmacy.

Am J Manag Care. 2013;19(10):798-804
Medication adherence, defined as taking medications as prescribed, is a key component in controlling disease progression and managing chronic illnesses.1,2 The clinical benefits of medication adherence have been well established in the scientific literature. Previous studies have indicated that medication adherence is associated with reducing disease morbidity,3 reducing healthcare resource utilization,4 decreasing hospitalization,5 improving effectiveness of treatment,6 and increasing likelihood of survival.7

In addition to worse health outcomes, medication nonadherence is linked to increased healthcare costs. Nonadherence across just  chronic therapy classes (antidiabetics, antihypertensives, and antihyperlipidemics) resulted in an estimated $105.8 billion in direct costs in the United States during 2010 alone.8 Nevertheless, this cost burden can be reduced. Previous studies have found that adherence rates of 80% or greater were associated with significant decreases in total medical costs for diabetes, hypertension, and high blood cholesterol.4

Studies have indicated that obtaining medication through the mail is one option for improved medication adherence.9-11 Compared with retail pharmacies, mail order has been touted as more cost-effective12 and convenient.13 In contrast, retail pharmacies are perceived to add value in terms of pharmacist face-to-face interaction.14-16 Proponents of mail order contend that medication  adherence is greater among patients who secure medications via mail order, while proponents of retail attribute any improved adherence to the increased days of supply per prescription in mail order.14

Many patients who intend to take their medications as prescribed fail to get medications refilled due to various factors such as inability to visit a pharmacy, their schedule, forgetfulness, or procrastination. Mail order provides a convenient and effective alternative for continued access to medications. Inadequate access17 and financial concerns18 are 2 factors identified as impediments to adherence.19 The impact of access and cost is reduced for many patients by the use of mail order, because  prescriptions are delivered to one’s home and the total patient out-of-pocket (OPP) costs are frequently less. Hence, we hypothesized that use of the mail order channel is associatedwith higher adherence rates than use of the retail channel.

A common limitation in adherence studies is the failure to control for underlying factors that affect adherence and selection of delivery channel. For example, it is quite possible that health-conscious individuals are more likely to have other healthy behaviors such as exercise, good diet, and preventive screenings. Hence, they may be more likely to engage proactively in activities that improve their adherence—sometimes referred to as the “healthy adherer” effect.20,21 Mail order generally provides more days of supply, regular refill reminders, and convenient reordering for members, mitigating the potential to procrastinate on medication refills, which can adversely affect adherence. Healthconscious individuals may choose the mail order channel to ensure continuity in their medication regimens. Thus, better medication adherence with mail order may reflect healthier patients’ predisposition to self-select the mail order option. To accurately attribute the impact of dispensing channel on adherence, it is important to control for bias from a patient’s predisposition to be adherent.

To our knowledge, previously published channel-adherence studies have not controlled for this potential confounder.13-15 A part of this effect, prior adherence behavior (PAB), can be controlled for by using a proxy measure—prior adherence, calculated based on pharmacy claims data. Also, most channel-adherence studies either have not fully controlled for differences in the days of supply between the 2 channels or have not taken patients’ choice of channel into account. This study aims to address the aforementioned biases and limitations, and tease out the effect of dispensing channel on adherence to medications to treat diabetes, hypertension, and high blood cholesterol.

METHODS

Study Population


This study used prescription claims data from a nationally representative sample of commercially insured members whose pharmacy benefits were managed by a large pharmacy benefit management company. Inclusion was limited to patients who were continuously enrolled for pharmacy benefits from April 1, 2009, until December 31, 2011, who were between the ages of 18 and 64 years, and who had any prescription claim for antidiabetics, antihypertensives, or antihyperlipidemics during the index period, which was from October 1, 2009, to December 31, 2009. Patients whose pharmacy benefit design required the use of mail order exclusively for maintenance medications or did not allow access to mail order (mandatory retail) at any time during the entire study period were excluded from analysis. That is, only those patients who were free to choose either channel at any time during the study to fill their maintenance prescriptions were selected. Under provisions of the Health Insurance Portability and Accountability Act of 1996, all data specific to individual patients were removed to maintain the privacy of protected health information from internal analytical data sets. All prescription claims were adjusted to 30-day equivalents.

Research Design

A retrospective claims analysis over a 3-year period divided into 4 distinct phases (Figure) was conducted. A 6-month look-back period from April to September 2009 was used to assess whether the patients were new or continuing users of the medications identified. Patients having a claim within  the same therapy class under study in the look-back period were categorized as continuing users and those without claims as new users. This indicator attempted to capture any differences in adherence that resulted from the longevity of treatment. The analysis period for this study was from January 1, 2011, to December 31, 2011. As previous adherence may be indicative of a health-conscious personality and a measure of  better health-seeking behavior,22 a patient’s prior adherence was used as a proxy control for self-selection bias due to the PAB effect in the multivariate model. Prior adherence was based on the patient’s medication possession ratio (MPR) in the year 2010, termed as the baseline period.

Study Variables

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Issue: October 2013
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