Identification of and intervention to address therapeutic gaps in care.

OBJECTIVES: To determine if therapeutic gap identification, notification of community pharmacists, and intervention results in increased gap closure, reduced gap closure time, and fewer adherence gaps reopening. STUDY DESIGN: Prospective, controlled, clusterrandomized study. METHODS: State of Illinois employees and beneficiaries of State health plans filling prescriptions at independently owned community pharmacies were included. For selected chronic conditions and medications, gaps in medication adherence and omitted essential therapies were identified from prescription claims and sent as alerts for resolution with the patient and/or physician. Adherence and omission gap closure at 90 days were analyzed with Kaplan-Meier (KM) survival curve approach and Cox proportional hazards models including covariates. RESULTS: A total of 1433 intervention and 1181 control adherence gaps were identified, while 677 intervention and 534 control omission gaps were generated. Pharmacists intervened on 639 (44.6%) adherence and 506 (74.7%) omission gaps. Gaps were closed more often in intervention than control at 30 days (55.5% in intervention vs 50.6% in control), 45 days (61.1% vs 58.4%, respectively), 60 days (66.1% vs 65.2%, respectively), and 90 days (73.0% vs 72.9%, respectively; adjusted hazard ratio [HR] = 1.242; P = .022; 95% confidence interval [CI] 1.115-1.385). Adherence gaps reopened less frequently in the intervention group (HR = 0.863; P = .012; 95% CI 0.769-0.968). A total of 89 (13.1%) intervention and 29 (5.4%) control omission gaps closed within 90 days (adjusted HR = 1.770; P = .005; 95% CI 1.182-2.653). CONCLUSIONS: Independent community pharmacists reduced gaps in care and had fewer reopened adherence gaps, suggesting improvement in adherence. A continuation study will examine the impact of the program on long-term adherence.

Antihypertensive medication adherence and subsequent healthcare utilization and costs.

OBJECTIVES: To evaluate the relationship between adherence to antihypertensive medications (AHMs) and subsequent hospitalizations, emergency department (ED) visits, and costs of care. STUDY DESIGN: Retrospective analysis of a national pharmacy benefits database of deidentified pharmacy and medical claims among patients with a diagnosis of hypertension. Adherence was estimated using the medication possession ratio (MPR). METHODS: Multivariate logistic and 2-part general linear models were estimated to study the relationship between adherence level (estimated by the MPR) and subsequent association with healthcare costs and cardiovascular (CV)-related hospitalizations and ED visits. RESULTS: We identified 625,620 patients with at least 2 claims for AHMs and divided them into 3 cohorts based on year 1 MPR of less than 60% (62,388 patients with low adherence), 60% to 79% (96,226 patients with moderate adherence), and 80% or higher (467,006 patients with high adherence). Patients with high adherence to AHMs were more likely to be older and male, have higher chronic disease scores and lower AHM copayments, and fill a greater percentage of prescriptions by mail order. Year 2 total mean (SD) adjusted healthcare costs were significantly lower for patients with an MPR of 80% or higher ($7182 [$27]) vs 60% to 79% ($7560 [$59]) or less than 60% ($7995 [$73]) (P <.001 for both). In addition, patients with low or moderate adherence had higher age- and sex-adjusted odds of CV-related hospitalizations (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.25-1.41) and ED visits (OR, 1.45; 95% CI, 1.33-1.58) (P <.001 for both). CONCLUSION: Adherence to AHMs is associated with significantly lower total healthcare costs and with significantly lower odds of CV-related hospitalizations and ED visits.

Frequency of follow-up care for adult and pediatric patients during initiation of antidepressant therapy.

OBJECTIVES: To measure the timing and frequency of follow-up care during the initiation phase of antidepressant therapy, and to compare the typical pattern of care with current product guidelines. STUDY DESIGN: Retrospective cohort study. METHODS: The study included 84514 adult and pediatric patients who started a new course of antidepressant therapy for any indication between July 2001 and September 2003. Patients were members of a large managed care organization in the northeastern United States. Ambulatory visits during the first 12 weeks of treatment were identified using medical claims data. Outcome measures were time to first follow-up visit, frequency of follow-up visits, and percentage of patients receiving recommended levels of care. RESULTS: During the first 4 weeks of treatment with antidepressants, only 55.0% of patients saw a healthcare provider for any purpose, and only 17.7% saw a provider for mental healthcare. Ambulatory visit rates during the first 4, 8, and 12 weeks were significantly lower than the minimum levels recommended in product labeling (P <.0001). Only 14.9% of patients received the Food and Drug Administration-recommended level of follow-up care during the first 4 weeks, 18.1% at 8 weeks, and 22.6% at 12 weeks. CONCLUSIONS: Adults and children who begin a new course of antidepressant therapy tend to receive far less monitoring than is recommended in current product labeling. Given safety concerns during the initiation phase, earlier and more frequent follow-up care appears desirable. Further research is needed to identify the most cost-effective schedule of care.