A systematic review of primary care-focused, self-reported medication adherence tools.

BACKGROUND: Clinician recognition of nonadherence is generally low. Tools that clinicians have used to assess medication adherence are self-reported adherence instruments that ask patients questions about their medication use experience. There is a need for more structured reviews that help clinicians comprehensively distinguish which tool might be most useful and valuable for their clinical setting and patient populations. OBJECTIVES: This systematic review aimed to (1) identify validated, self-reported medication adherence tools that are applicable to the primary care setting and (2) summarize selected features of the tools as an assessment of clinical feasibility and applicability. METHODS: The investigators systematically reviewed MEDLINE via Ovid, Embase via Ovid, International Pharmaceutical Abstracts, and CINAHL from inception to December 1, 2020. Investigators independently screened 3394 citations, identifying 43 articles describing validation parameters for 25 unique adherence tools. After screening each tool, 17 tools met the inclusion criteria and were qualitatively summarized. RESULTS: Findings highlight 25 various tool characteristics (i.e., descriptions, parameters and diseases, measures and validity comparators, and other information), which clinicians might consider when selecting a self-reported adherence tool with strong measurement validity that is practical to administer to patients. There was much variability about the nature and extent of adherence measurement. Considerable variation was noted in the objective measures used to correlate to the self-reported tools' measurements. There were wide ranges of correlation between self-reported and objective measures. Several included tools had relatively low to moderate criterion validities. Many manuscripts did not describe whether tools were associated with costs, had copyrights, and were available in other languages; how much time was required for patients to complete self-report tools; and whether patient input informed tool development. CONCLUSION: There is a critical need to ensure that adherence tool developers establish a key list of tool characteristics to report to help clinicians and researchers make practical comparisons among tools.

Improving care transitions through medication therapy management: A community partnership to reduce readmissions in multiple health-systems.

OBJECTIVES: The primary objective was to measure the impact of a pharmacist-provided medication therapy management program on 30-day postdischarge readmission rates. The secondary study objectives were to characterize the number and types of pharmacist interventions, to determine the impact of the intervention on primary and secondary medication nonadherence, and to measure patient satisfaction with the intervention. DESIGN: Randomized, clinical trial. SETTING: Six hospitals and a supermarket pharmacy chain with 60 pharmacies. PARTICIPANTS: Four hundred patients discharged from a participating hospital with acute myocardial infarction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, or diabetes. MAIN OUTCOME MEASURES: Primary outcome measure was 30-day readmission rate. Secondary outcomes were pharmacist interventions, primary and secondary medication nonadherence, and patient satisfaction. RESULTS: Four hundred patients were enrolled. There was not a significant difference in 30-day readmission rates between intervention and control groups (11.3% vs. 10.7%; P = 0.49). A large portion of patients randomized to the intervention did not attend their appointment. In a per protocol (PP) analysis, which included the 62 intervention patients who attended their appointment and the 187 patients in the control group, there was a significant difference in 30-day readmission rates (1.6% vs. 10.7%; P = 0.02). In the PP analysis, controlling for baseline differences, patients in the intervention group were significantly less likely to experience a readmission (odds ratio, 0.126; 95% confidence interval, 0.016-0.968; P = 0.046). In the PP analysis, the percentage of prescriptions not picked up in the intervention group compared with the control group was reduced by 2.5%, (6.4% vs. 8.9%; P = 0.59). Pharmacists identified many interventions, averaging 6 per patient. CONCLUSION: This study successfully implemented a large-scale transition of care program between multiple health systems and community pharmacies that reduced hospital readmissions. Pharmacists identified many interventions for patients. The transmission of patient information from the inpatient setting to the community pharmacy is key to transitioning patients successfully.

Addressing primary nonadherence: A collaboration between a community pharmacy and a large pediatric clinic.

OBJECTIVES: To decrease nonadherence rates through the design and implementation of a collaborative prescription management program involving a community pharmacy and a large pediatric primary care center. PRACTICE INNOVATION: Kroger and Cincinnati Children's Pediatric Primary Care Center collaborated to identify and address patients' barriers to filling new prescriptions. After filling new medications for clinic patients, pharmacists telephoned patients to inform them that their prescription was ready and to reinforce the importance of initiating the therapy. Pharmacists followed up with families to address barriers when prescriptions remained at the pharmacy after 48 hours. Pharmacists communicated with prescribers if prescriptions were not filled, allowing the clinic staff to follow up. EVALUATION: The primary outcome of this prospective pilot study with a comparison group was primary nonadherence (PNA), defined as the proportion of patients who did not pick up prescriptions or a reasonable alternative within 30 days after the pharmacy received the prescription. Secondary outcomes were the impact on secondary nonadherence and identification of adherence barriers. RESULTS: Fifty-nine patients were enrolled from November 2016 to April 2017. Characteristics between the intervention group and a standard-care group were similar. The majority of prescribed medications were for acute conditions, the average patient age was 4.9 years, and 86% of patients were covered by Medicaid. Intervention patients had significantly less PNA compared with the standard-care group (14.0% vs. 53.3%, respectively; P < 0.001). Intervention patients had significantly greater secondary adherence rates compared with standard-care patients (38.8% vs. 7%; P < 0.001). Common barriers likely resulting in PNA included lack of time, lack of urgency, transportation challenges, and cost. CONCLUSION: Increased communication between the primary care provider and the community pharmacy, coupled with targeted patient-specific interventions before the initial fill of medications, resulted in significant reductions in PNA.

Poverty, Transportation Access, and Medication Nonadherence.

BACKGROUND AND OBJECTIVES: Variability in primary medication nonadherence (PMN), or failure to fill a new prescription, influences disparities and widens equity gaps. This study sought to evaluate PMN across 1 metropolitan area and assess relationships with underlying zip code-level measures. METHODS: This was a retrospective observational study using data extracted from 1 regional community pharmacy market-share leader (October 2016-April 2017). Data included patient age, sex, payer, medication type, and home zip code. This zip code was connected to US census measures enumerating poverty and vehicle access, which were treated as continuous variables and within quintiles. The prescription-level outcome was whether prescriptions were not filled within 30 days of reaching the pharmacy. The ecological-level outcome was PMN calculated for each zip code (numerator, unfilled prescriptions; denominator, received prescriptions). RESULTS: There were 213 719 prescriptions received by 54 included pharmacies; 12.2% were unfilled. Older children, boys, and those with public insurance were more likely to have prescriptions not filled. Prescriptions originating from the highest poverty quintile were significantly more likely to not be filled than those from the lowest poverty quintile (adjusted odds ratio 1.60; 95% confidence interval 1.52-1.69); a similar pattern was noted for vehicle access (adjusted odds ratio 1.77; 95% confidence interval 1.68-1.87). At the ecological level, there were significant, graded relationships between PMN rates and poverty and vehicle access (both P < .0001); these gradients extended across all medication classes. CONCLUSIONS: Poverty and vehicle access are related to significant differences in prescription- and ecological-level PMN across 1 metropolitan area. Pharmacists and pharmacies can be key partners in population health efforts.

An appointment-based model to systematically assess and administer vaccinations.

OBJECTIVES: To incorporate the assessment of vaccination status and administration of vaccines in an appointment-based model (ABM) and measure the impact on vaccinations administered and patient and pharmacist satisfaction with the appointment-based model. PRACTICE DESCRIPTION: An ABM was implemented to systematically assess vaccination status and administer vaccines. Patients made an appointment to pick up synchronized prescriptions, and pharmacists assessed vaccination histories and administered vaccinations during the appointment. In addition, pharmacists could access the statewide immunization information system to objectively determine vaccination histories and document administered vaccines. SETTINGS AND PARTICIPANTS: This project was conducted at 24 Kroger Pharmacies in the Cincinnati-Dayton Area. Any patient filling more than 1 maintenance medication was eligible for the ABM program. Pharmacists were encouraged to target patients at high risk for medication problems and vaccine-preventable diseases, including patients 60 years of age or older with more than 5 medications and high-risk disease states such as diabetes, asthma, and chronic obstructive pulmonary disease. EVALUATION: Pharmacies were randomized, and an a priori analysis was conducted to ensure that the 24 intervention and 78 control stores were similar at baseline. Postimplementation data on the mean number of vaccines per store were compared between the intervention stores and the control stores from September 2014 through December 2015. Patient and pharmacist satisfaction with the ABM was assessed via surveys. RESULTS: The pharmacist vaccine assessment as part of the ABM program showed higher overall mean vaccinations per store compared with the control group during the project period (1810.71 ± 500.88 vs. 1455.09 ± 754.43; P = 0.01). Patients and pharmacists felt that the ABM program facilitated vaccine discussions. CONCLUSION: The ABM program with a focus on vaccinations allowed pharmacists to systematically assess patient vaccination histories and administer vaccines in the pharmacy. Patients and pharmacists appreciated the dedicated time to discuss vaccinations.

Appointment-based models: A comparison of three model designs in a large chain community pharmacy setting.

OBJECTIVES: To compare the effects of 3 different appointment-based model (ABM) designs on medication adherence and medication use outcomes controlling for patient and pharmacy characteristics. METHODS: This study was a retrospective cohort analysis in a large grocery store chain from January 1, 2012, to October 31, 2015. A total of 500 comparison and 613 intervention patients in 3 different model designs were analyzed. The outcome measures were proportion of days covered for selected medication classes, number of fills, administered vaccinations, number of trips, statin use in persons with diabetes, use of high-risk medications in older adults, and medication therapy for persons with asthma. RESULTS: After adjusting for relevant covariates, the authors found that all of the ABM designs significantly increased the number of fills after enrollment. Model designs 1 and 3 also significantly reduced the number of trips after enrollment: 4.5 fewer trips (95% CI -5.3 to -3.8; P < 0.05) for model 1 and 1.9 fewer trips (95% CI -3 to -0.9; P < 0.05) for model 3. Models 1 and 3 increased the percentage of patients considered to be adherent for diabetes medications and increased the number of vaccinations patients received. Models 1 and 2 significantly increased the percentage of patients considered to be adherent for statins. No model design was significantly associated with statin use in diabetes, high-risk medication use in older adults, nor percentage of patients considered to be adherent for the hypertension measure. CONCLUSION: All of the ABM designs were effective at increasing the number of fills after enrollment. This paralleled an increase in percentage of patients considered to be adherent to diabetes and statin therapies after enrollment. Models that included face-to-face delivery of the appointment and telephonic synchronization, or face-to-face delivery for all components, increased the number of vaccinations that patients received after enrollment and significantly reduced the number of trips a patient made to the pharmacy.

Community pharmacist collaboration with a patient-centered medical home: Establishment of a patient-centered medical neighborhood and payment model.

OBJECTIVES: To determine the feasibility of a partnership between a community pharmacy and a patient-centered medical home (PCMH) by measuring the impact on office- and patient-level clinical outcomes. SETTING: Kroger Pharmacy and a PCMH practice in Cincinnati, OH. PRACTICE DESCRIPTION: The Kroger Co. is a large grocery store chain that operates 102 pharmacies in the Cincinnati-Dayton marketing area. The PCMH practice is an accredited PCMH office serving more than 9000 patients in the Cincinnati area. PRACTICE INNOVATION: In a medical neighborhood, a PCMH coordinates care with other local specialty practices or partners. A partnership between the community pharmacy chain and the PCMH was established to create a medical neighborhood. The pharmacist spent 2 half-days per week at the PCMH. The pharmacist provided initial medication therapy management appointments in the PCMH and offered follow-up services in the office, the pharmacy, or both, depending on patient preference. The pharmacy received a capitated payment per patient per month for a predetermined number of 1000 high-risk patients. MAIN OUTCOME MEASURES: Office-level changes in clinical outcomes such as A1C, blood pressure, and lipid measures were collected and compared with those of a similar control office. In addition, patient-level outcomes such as change in A1C, blood pressure, lipids, and weight were measured. RESULTS: One hundred five patients were seen by the pharmacist during the study period, with 1.5% of the total managed at the office. There was a statistically significant increase in influenza vaccinations received. On a patient level, A1C and systolic blood pressure significantly improved. CONCLUSION: This project represents an exciting opportunity for community pharmacists to expand their scope of services through direct partnership with PCMHs and maintain a sustainable reimbursement structure.

Clinical outcomes of switching from insulin glargine to NPH insulin in indigent patients at a charitable pharmacy: The Charitable Insulin NPH: Care for the Indigent study.

OBJECTIVES: To assess the clinical outcomes of indigent patients with type 2 diabetes served by a charitable pharmacy after therapy change from insulin glargine to NPH insulin. DESIGN: This was a 24-week prospective pilot study. SETTING: Community charitable pharmacy. PARTICIPANTS: Underserved, financially disadvantaged adults with type 2 diabetes. INTERVENTION: Conversion from insulin glargine to NPH insulin. MAIN OUTCOME MEASURES: HbA1c, 30-day average blood glucose, number of suspected and confirmed hypoglycemic episodes, total insulin dose, and Morisky Medication Adherence Scale (MMAS) scores. RESULTS: Patients in both control and intervention groups improved in disease-state clinical markers, safety profile, and total insulin dose. MMAS scores were unchanged. CONCLUSION: There were no statistically significant differences in glycemic control or hypoglycemic episodes between the control (NPH insulin) or intervention group (insulin glargine to NPH insulin).

Pediatric asthma medication therapy management through community pharmacy and primary care collaboration.

OBJECTIVES: To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy. SETTING: Underserved inner city of Cincinnati, OH. PRACTICE DESCRIPTION: A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Children's Hospital Medical Center's (CCHMC) 3 pediatric primary care centers. PRACTICE INNOVATION: Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations. EVALUATION: Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures. RESULTS: Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively. CONCLUSION: This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives.

Health Beliefs Describing Patients Enrolling in Community Pharmacy Disease Management Programs.

OBJECTIVES: The purpose of this study was to survey new enrollees in a community pharmacy, employer-based diabetes and hypertension coaching program to describe the characteristics, health beliefs, and cues to action of newly enrolled participants. METHODS: A 70-question, 5-point Likert-type survey was developed using constructs from the Health Belief Model (HBM), Theory of Planned Behavior (TPB), and Theory of Reasoned Action (TRA). New enrollees in the coaching programs completed the survey. Survey responses between controlled and uncontrolled patients and patient demographics were compared. RESULTS: Between November 2011 and November 2012, 154 patients completed the survey. Patients were fairly well controlled with a mean hemoglobin A1C of 7.3% and a mean blood pressure of 134/82 mm Hg. The strongest cue to action for enrollment was the financial incentives offered by the employer (mean: 3.33, median: 4). White patients were significantly more motivated by financial incentives. More patients indicated they had not enrolled previously in the program because they were unaware it was available (mean: 2.89, median 3.0) and these patients were more likely to have an uncontrolled condition (P ≤ 0.050). CONCLUSION: A top factor motivating patients to enroll in a disease management coaching program was the receipt of financial incentives. Significant differences in HBM, TPB, and TRA responses were seen for patients with different demographics.

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate.

OBJECTIVES: To determine if a community pharmacy-based transition of care (TOC) program that included the full scope of medication therapy management (MTM) services (TransitionRx) decreased hospital readmissions, resolved medication-related problems, and increased patient satisfaction. DESIGN: Prospective, quasi-experimental study. SETTING: Nine Kroger Pharmacies located in Western Cincinnati. PATIENTS: Patients older than 18 years of age and discharged from two local hospitals with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. Patients were recruited from two local hospitals and referred to the community pharmacy for MTM services with the pharmacist within 1 week of discharge. MAIN OUTCOME MEASURES: Pharmacists reconciled the patients' medications, identified drug therapy problems, recommended changes to therapy, and provided self-management education. At 30 days after discharge, research personnel conducted telephone surveys, using a previously validated survey instrument, to assess hospital readmissions and patient satisfaction. Pharmacist interventions and medication-related problems were documented. RESULTS: A total of 90 patients completed the study. Of these, 20% of patients in the usual care group were admitted to the hospital within 30 days compared with 6.9% of patients in the intervention group (P = 0.019). In the 30 patients who received MTM services from the pharmacist, 210 interventions were made. The overall mean patient satisfaction with the TOC process was not significantly different between patients who were seen by the pharmacist and those who were not seen by the pharmacist. CONCLUSION: Community pharmacies successfully collaborated with hospitals to develop a referral process for TOC interventions. Patients who received MTM services from the pharmacist experienced significantly fewer readmissions than patients who received usual care.

Impact of the pay-for-performance-for-patients program for diabetes management.

OBJECTIVES: To determine whether patients with diabetes who used a financial rewards program in a grocery chain pharmacy had increased rates of self-reported healthy behaviors, to measure the impact of the program on glycosylated hemoglobin (A1C), and to measure the impact of the program on grocery store sales. METHODS: This prospective study took place at one location of a grocery chain pharmacy in Cincinnati, OH. Adult patients with diabetes on at least one diabetes medication were eligible to participate. Participants received a $5 incentive for each weeklong behavior log completed and reviewed with the pharmacist, who provided counseling on improving healthy behaviors. Change in self-reported healthy behaviors, A1C, grocery store expenditure, and program satisfaction were measured. RESULTS: During the 12-week study, 25 patients enrolled in the program. A total of 13 participants completed the poststudy survey and reported increased rates of self-monitoring of blood glucose and blood pressure and increased exercise frequency. Differences in A1C and grocery store expenditures were unable to be detected. Satisfaction with the pay-for-performance-for-patients (P4P4P) program was favorable (8.6 on a 10-point scale). CONCLUSION: Participants given small, frequent financial incentives had increased frequency of healthy behaviors and were satisfied with the P4P4P program.

U.S. emergency departments visits resulting from poor medication adherence: 2005-07.

OBJECTIVES: To describe characteristics and trends for emergency department visits related to medication nonadherence and to identify associations between patient characteristics and emergency department visits related to medication nonadherence. DESIGN: Retrospective cross-sectional study. SETTING: National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 to 2007. PATIENTS: Patients who had an emergency department visit for medication nonadherence. INTERVENTION: NHAMCS data were weighted to yield national estimates of emergency department visits related to medication nonadherence. Descriptive frequencies were calculated for visits related and unrelated to medication adherence. A binary logistic regression model was used to identify covariates for nonadherence. MAIN OUTCOME MEASURES: National estimates of emergency department visits related to medication nonadherence. RESULTS: An estimated 456,209 ± 68,940 (mean ± SD) nonadherence-related visits occurred. Of visits related to nonadherence, 29% resulted from mental health disorders. Significant covariates of nonadherence-related visits included age, payment source, and primary diagnosis. Visits for patients with mental illness (odds ratio 22.74 [95% CI 14.68-34.20]), type 2 diabetes (15.80 [5.20-48.06]), nondependent abuse of drugs (11.85 [3.83-36.65]), or essential hypertension (11.06 [3.99-30.61]) were significantly associated with the probability that an emergency department visit was related to nonadherence. More than 20% of emergency department visits related to medication nonadherence resulted in hospital admission, whereas only 12.7% of visits unrelated to nonadherence resulted in hospital admission ( P < 0.0001). CONCLUSION: Medication nonadherence is an important problem. Targeting patients at high risk for nonadherence, especially patients with mental illness, may improve medication adherence and prevent future emergency department visits.