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Safety and Effectiveness of Mail Order Pharmacy Use in Diabetes
Julie A. Schmittdiel, PhD; Andrew J. Karter, PhD; Wendy T. Dyer, MS; James Chan, PharmD, PhD; and O. Kenrik Duru, MD, MSHS
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Safety and Effectiveness of Mail Order Pharmacy Use in Diabetes

Julie A. Schmittdiel, PhD; Andrew J. Karter, PhD; Wendy T. Dyer, MS; James Chan, PharmD, PhD; and O. Kenrik Duru, MD, MSHS
Patients using mail order pharmacies have lower healthcare utilization, but somewhat less laboratory monitoring of persistent medications and slightly higher contraindicated medication use.
Mail order pharmacy services, which are provided at the healthcare delivery system level rather than the physician or practice level, can be considered a structural or system-level intervention for improving access to chronic illness medications.3,7 While this study and others3-7 suggest that using mail order pharmacy services may improve outcomes, our study also suggests that certain patients may be more sensitive to any potential negative impact of mail order pharmacy use on healthcare access. System-level efforts to promote mail order use should preserve patient choice in pharmacy services and maintain a patient-centered approach to meeting an individual’s overall healthcare needs. Future research should continue to address the important issue of how to appropriately target and promote mail order pharmacy services while preserving the benefits of in-person interaction with pharmacists and other care providers.

This study has several limitations. Observational studies cannot entirely control for differences between patients who use mail order pharmacy services and those who do not. While our sensitivity analysis demonstrated that the relationship between mail order pharmacy use and our outcomes would still be observed even in the presence of a powerful, prevalent confounder, future research should leverage randomized controlled trial designs to examine the impact of mail order pharmacy use on intermediate outcomes, healthcare utilization, and patient safety.

We were unable to ascertain pharmacy utilization at non-KPNC pharmacies. However, we limited our analyses to members with a drug benefit, which is only recognized at KPNC pharmacies. This under-ascertainment should be minimal, as previous research suggests that diabetes patients with drug benefits report extremely low use of non-KPNC pharmacies.26

This study was conducted in an integrated delivery system where patients access prescription medications differently than in many other settings. Use of “brick and mortar” pharmacies to fill prescriptions is primarily limited to KPNC local pharmacies; KPNC’s mail order and local pharmacies do not differ in the standard days of supply of pills issued; and mail order pharmacy does not require physician enrollment of the prescription. In addition, KPNC local pharmacies are primarily co-located with medical offices and laboratories, which is often not the case in other settings. This co-location may make any relationship between in-person pharmacy use and preventive care services stronger than in cases where patients obtain in-person refills from brick-and-mortar pharmacies that are not integrated with outpatient care. It is therefore possible that the use of mail order pharmacy services in KPNC has a different impact on outcomes than it would have in other settings.


Mail order pharmacy use is not associated with adverse events in most diabetes patients and may be associated with improved health outcomes. System-level interventions to increase mail order pharmacy use may be an important strategy for improving processes and outcomes of care for patients with chronic illness; however, these interventions should use a patient-centered approach that does not increase risk in older patients and others who may be sensitive to primary and preventive care access.

Author Affiliations: From Division of Research (JAS, AJK, WTD), Pharmacy Outcomes Research Group (JC), Kaiser Permanente Northern California, Oakland, CA; David Geffen School of Medicine (KD), University of California, Los Angeles; Los Angeles, CA.

Funding: This study was funded by the Division of Diabetes Translation, Centers for Disease Control and Prevention, contract CDC U58 DP002641. This activity was also supported by the Health Delivery Systems Center for Diabetes Translational Research (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] grant 1P30-DK092924), the Diabetes Study of Northern California (NIDDK grant R01 DK080726), and the Diabetes and Aging Study (NIDDK grant R01 DK0817960); the Harold Amos Medical Faculty Development Program from the Robert Wood Johnson Foundation; and the National Institute on Aging (grant K08 AG033630). The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding organizations.

Author Disclosures: The authors (JAS, AJK, WTD, JC, OKD) 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 (JAS, AJK, OKD); acquisition of data (JAS, AJK, WTD); analysis and interpretation of data (JAS, WTD, JC, OKD); drafting of the manuscript (JAS); critical revision of the manuscript for important intellectual content (AJK, JC, OKD); statistical analysis (WTD); obtaining funding (JAS, AJK); administrative, technical, or logistic support (JC); and supervision (JAS).

Address correspondence to: Julie A. Schmittdiel, PhD, Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612. E-mail:
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