Kara Zivin Bambauer, PhD
Stephen Soumerai, ScD
Alyce Adams, PhD
Fang Zhang, PhD
Rick Weisblatt, PhD
Neil Minkoff, MD
Andrea Grande, RPh
Dennis Ross-Degnan, ScD
Harvard Pilgrim Health Care and Harvard Medical School
„ The burden of depression is substantial
„ Effective medications are available to treat depression
„
Non-adherence to antidepressants remains a substantial problem
„ Harvard Pilgrim Health Care (HPHC) sought to improve quality of care for depression using available electronic data
„
To evaluate the effectiveness of providing faxed feedback to physicians regarding patient refill behavior
„ Does the proportion of patients who are potentially non-adherent to treatment decrease after the policy?
„ Does the proportion of days within a treatment episode without antidepressant coverage decrease after the policy?
„
Introduction: This is a clinical reminder to assist physicians who are treating patients for Major Depressive Disorder (MDD)
„
Explanation: There are 3 quality of care measures for depression treatment
„
Summary: information on antidepressant compliance
„
Symptoms usually remit in 4-6 weeks
„
„
Therapy should be continued for 6 months
Only 40% of patients of patients adhere to antidepressant treatment
„
Closing: Your patient (insert name) has gone more than 10 days without antidepressant treatment (medication name, dose, quantity)
„
Adherent: antidepressant prescription refilled within 10 days of an expected refill
„ If not, a fax is sent to the prescribing physician
„
Potentially non-adherent: antidepressant prescription refilled more than 10 days and less than 30 days after an expected refill
„
Failure: antidepressant prescription not refilled within 30 days of an expected refill
„
The prescribing physician receives the fax
„ The physician makes contact with the patient
„
A physician-patient conversation occurs that effectively deals with the reasons for patient non-adherence
„
The patient subsequently refills the antidepressant prescription in a timely manner
1

„
All HPHC members were eligible
„
All types of providers were included
„
Each patient needed to be enrolled for 6 months before and 6 months after first antidepressant use
„
Patients were included who used a select subset of antidepressants usually indicated for treatment of depression
„
New users of antidepressants (no use in previous 100 days)
„
First episode of antidepressant treatment for each person
„
Age ≥ 18
„
„
Interrupted time-series (ITS) analysis using SAS PROC AUTOREG
Used to evaluate rates of change in adherence due to the ACP
„ Look at slope and level changes
„
ITS is one of the strongest quasi-experimental designs for studying policy changes
„
„
„
Mean age (sd): 42 (11)
Gender: 69% female
Policy Variables
„
„
Adherent: 18%
Potentially non-adherent: 29%
„ Failure: 53%
„
No significant differences in pre-policy and post-policy patients
Percent of Non-Adherent Patients Who Proceed to
Adherence Failure
100%
90%
80%
70%
60%
50%
Pre-ACP period
First year of
ACP
40%
30%
20%
10%
Phase-in period
0%
May-02 Aug-02 Nov-02 Feb-03 May-03 Aug-03 Nov-03 Feb-04 May-04
% w/gaps & fail model expected
Mean Percent of Treatment Days Not Covered
100%
90%
80%
70%
60%
50%
Pre-ACP period
First year of
ACP
40%
30%
20%
10%
Phase-in period
0%
May-02 Aug-02 Nov-02 Feb-03 May-03 Aug-03 Nov-03 Feb-04 May-04
% coverage model expected
2

„ Electronic reminder systems, while popular, may not improve patient adherence
„ Success of such interventions requires a complex chain of events to occur
„
We cannot determine from electronic data whether communication between physicians and patients addresses reasons for patient non-adherence
„
Stand alone interventions targeting adherence are not successful
„
The ACP was not successful at increasing antidepressant adherence rates in HPHC members
„
Additional research should re-examine assumptions underlying the ACP to identify ways to improve future antidepressant adherence interventions
„
Effectiveness of electronic interventions should be carefully evaluated before widespread implementation
3