The American Journal of Managed Care March 2016
Prevalence, Effectiveness, and Characteristics of Pharmacy-Based Medication Synchronization Programs
Objectives: The burden of visiting pharmacies to fill medications is a central contributor to nonadherence to maintenance medications. Recently, pharmacies have begun offering services that align prescription fill dates to allow patients to pick up all medications on a single visit. We evaluated the prevalence and structure of synchronization programs and evidence of their impact on adherence and clinical outcomes.
Study Design: Mixed-methods approach consisting of semi-structured interviews, data from surveillance activities, and a systematic literature review.
Methods: We conducted interviews with opinion leaders from nonprofit advocacy organizations and exemplary synchronization programs. Program prevalence was determined using data from regular surveillance efforts. A literature review included Medline, EMBASE, Google Scholar, and general Internet searches.
Results: Synchronization programs exist in approximately 10% of independent, 6% of stand-alone chain, and 11% of retail store pharmacies. The majority of programs include a monthly pharmacist appointment and reminder communication. Programs reported the importance of pharmacist buy-in, technology to track and recruit patients, links to other healthcare services, and flexible solutions for managing costs and communication preferences. Although existing peer-reviewed literature suggests that synchronization improves adherence, more evidence is needed to evaluate its impact on patient-centered outcomes.
Conclusions: As medication synchronization programs shift directions and compete for patients and payer resources, it will be more important than ever to rigorously evaluate their ability to improve clinical outcomes while also providing the growing number of patients managing multiple chronic conditions with the highest level of patient engagement and consumer choice.
Am J Manag Care. 2016;22(3):179-186
- An estimated 8% of US pharmacies offer a medication synchronization program—a rate that nearly doubled from 2013 to 2014.
- Synchronization programs are based on 2 core models with additional features, including technology to track and recruit patients, links to other healthcare services, and flexible solutions for patients to manage medication costs and communication preferences.
- As programs expand, more attention will need to be devoted to care continuity and cost.
Patients with chronic conditions must often manage medications prescribed by numerous physicians and may fill their prescriptions on many different days. For example, patients with cardiovascular disease make an average of 20 pharmacy visits annually, and the top decile make more than 43 visits.8 This makes establishing a routine around medication filling challenging, especially when insurance restrictions frequently prohibit refilling until the supply from the prior prescription has been nearly exhausted. The resultant impact on adherence for patients whose prescriptions’ fill dates are not aligned appears to be very large.8,10-12
To overcome this problem, pharmacies have begun to offer “medication synchronization” services that aim to simplify the refilling process by allowing patients to pick up all of their medications on a single visit. To accomplish this, patients receive partial supplies of their medications in order to align their subsequent refill dates. Medication synchronization programs—which in addition to prescription synchronization often include other pharmacy-based services, such as medication management counseling or vaccination—have attracted substantial and growing enthusiasm.13 Initial estimates of their impact suggest that, depending on drug class, medication synchronization programs may improve adherence up to 6-fold.14,15 However, to date, little is known about these programs, how they have been implemented, who they serve, and what features appear to be associated with their success.
Prevalence and Program Structure
To determine the prevalence, scope, and characteristics of existing programs, we conducted interviews with opinion leaders from the National Community Pharmacist Association (NCPA) and Pharmacy Quality Alliance, organizations that have been actively involved in monitoring, developing, and promoting medication synchronization programs. Three investigators conducted in-depth 60-minute telephone interviews, between January and March 2014. Interviewers used a written guide that contained a list of key thematic areas and kept written notes, which were reconciled after every interview. The interviews were semi-structured, with questions designed to elicit insight into the origins of synchronization programs, their current state, and future challenges. This study was approved by the Institutional Review Board at Brigham and Women’s Hospital.
The prevalence of synchronization programs in chain and retail store pharmacies was determined through data collected from our opinion leaders who systematically survey program administrators biannually by e-mail or telephone. Programs report the number of stores with a synchronization program, the number of patients enrolled, and the projected estimates of patient enrollment, which enables leaders to reconcile new data with past projections. This surveillance approach captures information from an estimated 80% to 90% of chain (stand-alone pharmacies with 4 or more stores) and retail store pharmacies (pharmacies embedded in retail outlets, such as supermarkets) nationwide. Program prevalence in independent pharmacies (stand-alone pharmacies with fewer than 4 stores) was ascertained using official and self-reported data collected by NCPA through quarterly surveys to all affiliated pharmacies.
Impact on Adherence and Clinical Outcomes
To estimate the impact of existing synchronization programs on adherence and clinical outcomes, we conducted a systematic review of the peer-reviewed literature in November 2014 using Medline and EMBASE. We sought to identify studies reporting original data on the impact of medication synchronization programs on adherence to chronic disease medications and on clinical outcomes.
From the abstracts identified through medical subject headings (MESH) and keywords for medication synchronization (N = 376), 111 met our criteria for medication adherence, and of these, 14 were selected for full text review. We excluded studies that did not evaluate a medication synchronization program (n = 2), did not evaluate adherence (n = 3), or for which no results were reported (n = 7). Our final sample consisted of 2 peer-reviewed studies.14,16 A review of reference lists of full text articles and personal archives to identify additional studies potentially missed by our search strategy did not yield additional results.
We also conducted Internet and Google Scholar searches using a variety of synonyms for “medication synchronization,” “adherence,” “persistence,” and several cardiovascular conditions. This strategy yielded 3 articles evaluating the impact of synchronization on adherence,17-19 1 evaluating the impact on systolic blood pressure,20 and 1 evaluating both adherence and cardiovascular biomarkers.21 To generate as complete a summary of the synchronization landscape as possible, we contacted the authors of peer-reviewed studies that did not present empirical results to obtain unpublished results. Two authors (AAK, DLI) conducted the systematic search and extracted data on study population, characteristics, results, and study limitations from each included article using standardized protocol and reporting forms.
Key Program Features and Innovations
To identify key features of synchronization programs, we asked our opinion leaders to nominate exemplary synchronization programs run by independent, chain, and retail store pharmacies. This process generated a consistent list of 7 exemplars. With 1 program declining to participate, our final list included 2 independent, 3 chain, and 1 retail store program.
For each nominated program, we conducted an interview with individuals who run or were involved in the program’s creation. As with opinion leader interviews, 3 investigators conducted telephone interviews lasting 30 minutes each, between April and October 2014, and reconciled written notes after every interview. Each interview began by describing the study objectives and design, and obtaining the consent of the interviewee(s) to have their perspectives included in our analysis. Interviews were guided by semi-structured questions about how standard programmatic features are implemented and program elements developed to maintain program stability, growth, and patient satisfaction. We continued our interviews until we believed we had achieved a broad array of perspectives, which we assessed by identifying common themes across responses at the conclusion of every new interview.
Medication synchronization programs were offered by approximately 10% of independent, 6% of chain, and 11% of retail pharmacy stores in 2014 (Table 1). Compared with chains, retail store pharmacies reported having 50% more participating pharmacies (1938 vs 1396, respectively). Median program enrollment was 4843 and 475 patients for chain and retail stores with a program, respectively.
All chain and retail store pharmacies with a synchronization program, which collectively have more than 350,000 patients enrolled,13 follow a model initially developed by Abrams and Clark independent pharmacy, which was formalized and expanded by the NCPA and the American Pharmacists Association.13,22 The key components of this approach, called the appointment-based model (ABM), are the alignment of prescription fill dates, a monthly call or text message to remind patients to pick up their medications, and a scheduled monthly appointment with comprehensive medication review or other medication therapy management.23
A second standardized program, which evolved from the original ABM framework and is branded specifically for independent pharmacies, is the Simplify My Meds (SMM) program. Developed by the NCPA as a resource package for independent pharmacists, the program is characterized by prescription synchronization and regular reminder calls, with less emphasis on monthly appointments.24 Over 2200 independent pharmacies in the United States have enrolled approximately 83,000 patients into programs using SMM.
Impact of Existing Programs on Adherence and Clinical Outcomes
The results of our systematic review of the impact of medication synchronization programs on adherence and clinical outcomes are presented in Tables 2 and 3. All studies except for 1 were observational and used either a control group or a pre-/post analysis with time as a control. Four studies were full-length reports or articles,14,17,20,21 1 was a published abstract,16 and 2 were conference posters.18,19 Studies also ranged in size, from pilots of fewer than 10 patients to a retrospective analysis of over 20,000 patients. Three studies evaluated the University of Mississippi RxSync program.16,18,19
All studies evaluating an adherence outcome measured adherence to antihypertensive, hyperlipidemic, and/or oral hypoglycemic therapy. The 2 peer-reviewed articles were the only ones to conduct statistical testing of results, both finding significantly higher adherence in synched patients compared with usual care, with up to 6-fold greater odds of patients being fully adherent (Table 3).14,19 Other studies demonstrated improved adherence or persistence due to synchronization with different lengths of follow-up; however, the small sample size suggests some are underpowered to detect significant differences.17,25,26 More information on study quality and limitations is presented in the eAppendix (available at www.ajmc.com).
Key Program Features and Innovations
Characteristics of the nominated exemplar programs are summarized in Table 4; 5 of these programs followed the ABM model, and 1 the SMM model. Four programs reported targeting patients taking 2 or more medications; 1 targets all patients regardless of medication count; and another only targets patients on an ad hoc basis, such as individuals who take many medications, seniors, and family caregivers. Exemplars identified 5 innovative features deemed critical to their program growth and success: