The American Journal of Managed Care July 2009
Impact of Workplace Health Services on Adherence to Chronic Medications
Patients who used workplace primary care and pharmacy services had higher adherence rates to medications for their chronic conditions than community-treated patients.
The literature points out that medication adherence rates tend to drop dramatically after the first 6 months of therapy when patients begin taking a new medication.7 This lack of persistence is due to a number of factors including side effects, lack of belief in the need for, or efficacy of, a given medication, cost, and inconvenience.18 We looked at the impact of workplace health services on patient adherence to new medications. New medication starts were defined as at least 1 pharmacy claim for a therapeutic class during the study year (2006) when the patient did not have a claim for the same therapeutic class during the baseline year (2005). The results of this analysis are shown in Table 3. Consistent with the literature, adherence in all 20 therapeutic classes was lower for patients with new medication starts than it was for patients at various points in their drug treatment continuum. However, like Table 2, Table 3 shows that workplace-treated patients had a higher MPR than community-treated patients for nearly all individual therapeutic classes as well as the combined classes.
Medication adherence is now recognized as an important contributor to effective chronic condition management. A number of strategies have been proposed to improve patient adherence with medications, including informational interventions, behavioral-based interventions, family and social interventions, or a combination of these approaches. Most have achieved limited success,19 with few significantly affecting clinical outcomes.20 Currently, an increasing level of attention is being directed toward overcoming identified financial barriers to medication acquisition. The economic justification for this approach—so-called value-based benefit design—is based on evidence that improved medication adherence results in significantly lower overall healthcare costs. Although recent studies demonstrate support for this model, adherence rates remain less than optimal,10 indicating that there is a need for a more comprehensive approach to increasing medication adherence.
A major limitation of each of these approaches is that the incentive to increase medication adherence is external. Although there may be a valid economic basis on which to justify 1 or more of these interventions, perhaps the most effective strategy is to ensure that patients sufficiently understand their diagnosis, the rationale for drug therapy, and the consequences of not taking their medications. When this information is sufficiently understood and internalized, external incentives may become secondary, particularly for those with reasonable wages and benefits. Internalizing the need to follow the treatment plan set out by a patient’s physician and reinforced by the patient’s pharmacist or other “trusted clinician” is a major step toward accepting responsibility for self-care.
The results from this study indicate that users of a workplace health service had statistically significant increases in medication adherence across many therapeutic classes compared with nonusers of workplace health services. Notably, when adherence was analyzed by quintiles, the data show that compared with the community-treated group, the workplace-treated group had a fairly consistent upward shift and comparative reductions in the percentage of patients in each of the low-quintile categories.
This broad-based upward shift in adherence for the workplace-treated group leads us to speculate that the observed increase in medication adherence might originate from the quality of the patient-provider relationship. In this trusted clinician role, providers can not only educate their patients about the importance of taking prescribed medications but also provide a true medical home that provides the follow-up and continuity of care that enhance the bond between clinician and patient with each encounter, creating the trust needed by patients to make the daily decision to actively participate in their treatment.21,22 It is important to note that no formal provider or patient education program regarding medication adherence was implemented during this study period; it is possible that a more focused program could have generated even more favorable adherence outcomes.
Anecdotally, increased adherence may be due to having a pharmacy at the workplace. Having both primary care and pharmacy services at the workplace is extremely convenient. Patients who have a medical visit can fill their prescription without leaving the health center, avoiding a trip to a community pharmacy or having to complete mail order forms to fill their prescriptions. There also is a social aspect of workplace primary care and pharmacy that might come into play for retirees in particular, as the workplace pharmacy providesan outlet for seeing people with whom they used to work. Patients also develop relationships with their trusted pharmacists, which might lead to a preference for face-to-face interactions over mail order. It also is possible that the amount of time spent on learning about disease states at the workplace health centers brings a heightened focus for the patient, the clinician, and the pharmacist on the importance of adherence to medication regimens.
This study has a number of limitations. First, the workplace-treated patients may represent a self-selected population that is, for some reason, more motivated to be adherent with their medication regimen than patients treated in the community. However, the demographics show that the 2 groups are at least somewhat similar and the differences observed were controlled for in the analysis, supporting the idea that the observed effect is due to the nature of the patient interaction within the workplace primary care and pharmacy. Additionally, the study fails to incorporate physician discontinuation of medication. Although the study design accounts for and includes switches of medication either within the same therapeutic class or (in the case of the grouped classes) by disease, claims data did not allow us to ascertain cases where a physician simply eliminated a prescription for a given drug class. Attempting to determine these cases would have required medical chart review, which was beyond the scope of this study. However, the impact of any possible medication stops by a clinician is unlikely to differ substantially between the workplace-treated and community-treated groups, so we feel the impact was minimal.
Next, adherence rates were calculated using claims data, which do not capture the actual rate at which patients took their medication, nor do these data capture prescriptions for which insurance was not used. However, as mentioned earlier, measurements of adherence using claims data are fairly standard in the literature.
These results support the concept of workplace healthcare delivery. In this setting, enhanced access to medical care facilitates patient education, with the goal of promoting responsibility for self-care. Nonadherence to medications results in an additional $100 billion in annual healthcare costs.8 As the number of Americans with chronic conditions rises, educating patients to take their medications regularly becomes more important. Although this is not a “one-size-fits-all” approach, workplace health services have the potential to save not only healthcare dollars, but lives as well.
Author Affiliations: From the Department of Internal Medicine (BWS), Case Western Reserve University, Cleveland, OH; Take Care Health Systems (SGF, RAB, JRM, JCD), Nashville, TN; and Take Care Health Systems (RJF), Chadds Ford, PA.
Funding Source: This study was funded by Take Care Health Systems, a wholly owned subsidiary of Walgreens.
Author Disclosure: Drs Glave Frazee, Fabius, Broome, Manfred, and Davis are employees of Take Care Health Systems, the funder of this study. Take Care Health Systems provides workplace pharmacy and primary care services as described in this article. Dr Fabius reports speaking at meetings and conferences on behalf of his employer. Dr Fabius also reports serving on the executive board and owning stock in CHD Meridian Healthcare, an integrated workplace healthcare provider later purchased by Walgreens. Dr Sherman
reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (BWS, SGF, RJF, JRM); acquisition of data (SGF, RJF, RAB); analysis and interpretation of data (BWS, SGF, RJF, JCD); drafting of the manuscript (BWS, SGF, RJF); critical revision of the manuscript for important intellectual content (BWS, SGF, RJF, RAB, JRM); statistical analysis (SGF, JCD); obtaining funding (RJF); administrative, technical, or logistic support (RJF, JRM); and supervision (SGF, RJF, RAB).
Address correspondence to: Sharon Glave Frazee, PhD, Health Informative and Research, Take Care Health Systems, LLC, 40 Barton Hills Blvd, Nashville, TN 37215. E-mail: email@example.com.
1. Munger MA, Van Tassell BW, LaFleur J. Medication nonadherence: an unrecognized cardiovascular risk factor. MedGenMed. 2007;9(3):58. Accessed August 21, 2008.
2. Ho PM, Magid DJ, Shetterly SM, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155(4):772-779.
3. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalizations and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166(17):1836-1841.
4. Simpson SH, Eurich DT, Majumdar SR, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ. 2006;333(7557):15.
5. Ho PM, Magid DJ, Shetterly SM, et al. Importance of therapy intensification and medication nonadherence for blood pressure control in patients with coronary disease. Arch Intern Med. 2008;168(3):271-276.
6. National Council on Patient Information and Education. Enhancing Prescription Medicine Adherence: A National Action Plan. August 2007. http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf. Accessed August 23, 2008.
7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.
8. Greene J, Hibbard J, Murray JF, Teutsch SM, Berger LB. The impact of consumer-directed health plans on prescription drug use. Health Aff (Millwood). 2008;27(4):1111-1119.
9. Keller DL, Wright J, Pace HA. Impact of health literacy on health outcomes in ambulatory care patients: a systematic review. Ann Pharmacother. 2008;42(9):1272-1281.
10. Chernew ME, Shah MR, Wegh A, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Aff (Millwood). 2008;27(1):103-112.
11. Frazee SG, Kirkpatrick P, Fabius R, Chimera J. Leveraging the trusted clinician: documenting disease management program enrollment. Dis Manag. 2007;10(1):16-29.
12. Frazee SG, Ryan P, Broome R, Fabius R, Manfred J. A prescription for appropriate antibiotics usage: physicians and pharmacists collaborate within a workplace health center. Journal for Health & Productivity. 2007;2(1):12-19. http://www.takecareemployersolutions.com/tpl/study2.pdf. Accessed June 29, 2009.
13. American Society of Health-System Pharmacists. AHFS Drug Information 2008. http://www.ahfsdruginformation.com/. Accessed January 2, 2008.
14. Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291(19):2344-2350.
15. Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11(1):44-47.
16. Kopjar B, Sales AE, Piñeros SL, Sun H, Li YF, Hedeen AN. Adherence with statin therapy in secondary prevention of coronary heart disease in Veterans Administration male population. Am J Cardiol. 2003;92(9):1106-1108.
17. Peterson AM, Nau DP, Cramer JA, Benner J, Gwadry-Sridhar F, Nichol M. A checklist for medication compliance and persistence studies using retrospective databases. Value Health. 2007;10(1):3-12.
18. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001;26(5):331-342.
19. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;(2):CD000011.
20. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167(6):540-550.
21. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease [published correction appears in Med Care. 1989;27(7):679]. Med Care. 1989;27(3 suppl):S110-S127.
22. Brookhart MA, Patrick AR, Schneeweiss S, et al. Physician follow-up and provider continuity are associated with long-term medication adherence; a study of the dynamics of statin use. Arch Intern Med. 2007;167(8):847-852.