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The American Journal of Managed Care November 2015
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Community Pharmacy Automatic Refill Program Improves Adherence to Maintenance Therapy and Reduces Wasted Medication
Olga S. Matlin, PhD; Steven M. Kymes, PhD; Alice Averbukh, MBA, MS; Niteesh K. Choudhry, MD, PhD; Troyen A. Brennan, MD, MPH; Andrew Bunton, MBA, CFA; Timothy A. Ducharme, MBA; Peter D. Simmons, RPh; and William H. Shrank, MD, MSHS
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Community Pharmacy Automatic Refill Program Improves Adherence to Maintenance Therapy and Reduces Wasted Medication

Olga S. Matlin, PhD; Steven M. Kymes, PhD; Alice Averbukh, MBA, MS; Niteesh K. Choudhry, MD, PhD; Troyen A. Brennan, MD, MPH; Andrew Bunton, MBA, CFA; Timothy A. Ducharme, MBA; Peter D. Simmons, RPh; and William H. Shrank, MD, MSHS
Evaluation of a national retail pharmacy automatic refill program for patients on medication for chronic disease demonstrated significantly improved patient adherence and reduced medication oversupply.
Improved medication adherence was obtained without an increase in medication oversupply. In the United States, there is particular concern with oversupply contributing to increased regimen complexity, opiate abuse, antibiotic resistance, and environmental toxicity.10 Some policy makers have expressed concern regarding the impact of medication wastage on limited healthcare budgets.11 We found that members enrolled in this automatic refill program were less likely to receive more than a year’s supply of medication and had less oversupply than did members of the matched control group. Interestingly, this was an outcome expected by commentators in Europe who conducted reviews and studies of similar refill programs. These authors suggested that putting the pharmacist in control of the refill process would reduce the tendency of the patient to stockpile medication, thus reducing oversupply.6,12 Our findings support this hypothesis.

We found high rates of oversupply in both cohorts—18% in the 30-day supply refill cohort and 19% in the control cohort—while among those receiving a 90-day supply, the proportions were 26.6% for the refill cohort and 27.8% for the control cohort. However, our findings support a hypothesis that automatic refill programs help to reduce, not exacerbate, the problem of prescription drug oversupply. Although further consideration regarding approaches to reduce oversupply is needed, it is not likely that placing barriers on the involvement of pharmacists in the prescription refill process will reduce the problem of medication oversupply.

Limitations

As with all research, our study has several limitations. First, this investigation considered the experience of 1 national retail pharmacy chain, so we cannot know the extent to which this experience is generalizable to other retail or mail-order pharmacies. However, CVS has a national footprint and our experience is likely representative of other national and regional chain pharmacies. Second, our adherence results are based upon pharmacy claims data; we cannot know if medication dispensed was actually taken, or by whom. Nonetheless, this is a common and well-accepted method to measure adherence. Third, patients in the refill cohort chose to participate in the program, whereas the controls were selected from a broader sample of CVS patients. Although we used propensity score matching to reduce confounding, and confirmed using well-accepted methods that our match was excellent, we cannot know the impact of unknown confounding factors, including self-selection bias, on our results. Therefore, we are careful not to overstate our confidence in our findings. If there is bias present, it favors improved adherence behavior, but the influence on oversupply behavior is less clear. Finally, we limited our examination to patients who were established medication users; however, among people with chronic disease, this reflects the vast majority of medication users.

 
CONCLUSIONS
Medication adherence remains a major public health problem, and improving adherence has been demonstrated to have an attractive return on investment. Easing the refill process is one method to remove barriers to adherence. We have demonstrated that automatic refill programs can improve adherence across a range of therapeutic classes and payer types, and we have also provided evidence that this improvement is gained without an increase in the frequency or magnitude of medication oversupply.

Acknowledgments

The authors gratefully acknowledge the contribution of Cullen Hagan for providing the data used in these analyses.

Author Affiliations: Division of Enterprise Research and Analytic Development, CVS Health (OSM, SMK, AA, TAB, AB, TAD, PDS, WHS), Northbrook, IL; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School (NKC), Boston, MA.

Source of Funding: The work was conducted by employees of CVS Health.

Author Disclosures: Drs Matlin, Kymes, Brennan, and Shrank, and Messieurs Bunton, Ducharme, and Simmons are employees of CVS Health. CVS provides an automatic refill program to patients and benefits from additional medication sales, which is addressed in the article text. Ms Averbukh was an employee of CVS Health when she conducted this work. Dr Choudhry receives research support from CVS Health, and has previously received grants from Merck, PhRMA, and others, all payable to his institution. The content is solely the responsibility of the authors and does not necessarily represent the official views of CVS Caremark.

Authorship Information: Concept and design (OSM, SMK, AB, NKC, TAB, TAD, PDS); acquisition of data (AA, TAB, PDS); analysis and interpretation of data (OSM, SMK, AA, AB, NKC, TAD, WHS); drafting of the manuscript (OSM, SMK, WHS); critical revision of the manuscript for important intellectual content (OSM, SMK, AB, NKC, TAB, TAD, PDS, WHS); statistical analysis (OSM, SMK, AA); and supervision (OSM, SMK, WHS).

Address correspondence to: Steven M. Kymes, PhD, CVS/caremark, 2211 Sanders Rd, NBT 326, Northbrook, IL 60062. E-mail: Steven.Kymes@CVSHealth.com.
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