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Identification of and Intervention to Address Therapeutic Gaps in Care
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Identification of and Intervention to Address Therapeutic Gaps in Care

Daniel R. Touchette, PharmD, MA; Sapna Rao, BPharm, MS; Purna K. Dhru, PharmD; Weihan Zhao, PhD; Young-Ku Choi, PhD; Inderpal Bhandari, PhD; and Glen D. Stettin, MD
A program identifying and resolving care gaps involving community pharmacists resulted in increased adherence and omission gaps closure and fewer adherence gap reopenings.
The third study also used a prospective, non-randomized design evaluating the impact of a nurse case-manager intervention in 155 “high-risk” patients with diabetes participating in a cardiovascular disease management program.17 Patients who were more than 60 days late to refill their prescriptions were referred to nurse case managers with training in health behavior change techniques for counseling on barriers to adherence and resources available to assist with medication adherence. Compared with control patients from a health plan without a diabetes disease management program, a significantly higher rate of prescription refills was observed in the intervention group (42.1% vs 59.3%, respectively). However, whether the program had any real impact on adherence is difficult to assess due to lack of randomization and because patients in the intervention had access to a diabetes disease management program not offered to control patients.

While reminders may be helpful for a few individuals, a more comprehensive intervention is generally needed to improve medication adherence.2 The timing and type of method by which information is conveyed to the patient is crucial to patient acceptance. Motivational interviewing has been proved useful in efficient patient communication and improvement in patient-provider relationship.24 In order to be considered sustainable, an intervention must be delivered by the pharmacist in a relatively short, cost-effective manner. We developed our intervention with these goals in mind. When used in conjunction with the community pharmacists’ existing patient relationships, and specialized knowledge of assessing and addressing adherence barriers, we anticipated that the community pharmacists would successfully effect behavior change in many patients.

With regard to omission errors, we identified only 1 publication.9 In this randomized, controlled study, prescription and physician claims were scanned for specific situations where a therapy or monitoring was absent, placing a patient at risk of an adverse or suboptimal outcome. Intervention alerts were sent directly to physicians. Of the 394 recommendations to start a new medication, 24% of the intervention group recommendations were initiated by physicians compared with 17% of medications being initiated in the control group over an unspecified period of observation (the study was conducted over a 12-month period), for a relative increase of 42%. In comparison, our study observed omission gap closures in 13.1% of intervention and 5.4% of control gaps, for a relative increase of 143%. The ability of the pharmacists to thoroughly evaluate the gap, screen out false positive gaps, and communicate the need for an omitted medication with the physician professional-to-professional may be responsible for the larger relative effect size we observed in this study.

There are several limitations to our study that must be acknowledged. First, the study assesses the short-term impact of the intervention on an intermediate outcome for adherence. While gap closure is a necessary step in improving adherence, whether facilitated gap closure is associated with long-term improvement in adherence has yet to be determined. Our analyses of adherence gap reopening and cumulative medication gaps hints at the potentially positive effect of the intervention on actual adherence, but still only for the shorter term. The long-term outcome of the intervention on adherence, as measured by proportion of days covered, is being assessed in a continuation phase of this study.

CONCLUSIONS

A program designed to identify adherence and omission gaps in care and utilizing community pharmacists to address those gaps significantly affected underutilization of medications. Specifically, the program resulted in increased adherence gaps closure over time, fewer adherence gap reopenings, and a considerable 143% relative increase in omission gap closures at 90 days.

Acknowledgments
The authors would like to thank the Illinois Pharmacists Association (IPhA), and specifically, IPhA’s executive director Mike Patton, for their support of this research study and the use of IPhA’s headquarters for conducting some of the pharmacist training programs. We acknowledge Mary Lynn Moody, PharmD, and Jessica Tilton, PharmD, for co-developing the pharmacist training program and all of the UIC mentors who participated in the live training sessions. We also acknowledge Karen Hartwig, Cheryl Hoffer, Kim Swiger, and Amardeep Singh from Mirixa Corporation for acting as the liaison with participating intervention pharmacists and support during the pharmacist training. Finally, we want to thank Shannon Denison, MA (former employee), and Stacey Decembrele, MPH, employees of Medco Health Solutions for their support in making this study a success.


Author Affiliations: From Department of Pharmacy Practice (DRT ), Department of Pharmacy Administration (SR), College of Pharmacy, University of Illinois at Chicago, Chicago, IL; Medco Health Solutions, Inc, Palatine, IL (PKD), Franklin Lakes, NJ (IB, GDS); Division of Epidemiology and Biostatistics (WZ), Institute for Health Research and Policy (Y-KC), School of Public Health, University of Illinois at Chicago, Chicago, IL.


Author Disclosures: Drs Bhandari and Stettin report stock ownership in Medco Health Solutions, Inc. The authors (DRT , SR, PKD, WZ) report 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 (DRT , SR, PKD, IB, GDS); acquisition of data (DRT , PKD, IB, GDS); analysis and interpretation of data (DRT , SR, PKD, WZ, IB, GDS); drafting of the manuscript (DRT , PKD, IB, GDS); critical revision of the manuscript for important intellectual content (DRT , PKD, WZ, IB, GDS); statistical analysis (DRT, SR, WZ, IB, GDS); provision of study materials or patients (PKD, IB, GDS); obtaining funding (DRT , IB, GDS); administrative, technical, or logistic support (DRT , PKD, IB, GDS); and supervision (DRT , PKD, IB, GDS).


Funding Source: Support for this research was provided through an unrestricted research grant provided by Medco Health Solutions to the University of Illinois at Chicago.


Address correspondence to: Daniel R. Touchette, PharmD, MA, Assistant Professor, University of Illinois at Chicago, College of Pharmacy, 833 S Wood St M/C 886, Chicago, IL 60612. E-mail: drtouche@uic.edu.
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