The Medication Adherence Program:
Promoting diabetes self-management through
community pharmacies
Presented by:
Peggy Odegard, PharmD, BCPS, CDE, FASCP
Associate Professor, University of Washington
Thank you
• The American Association of
Diabetes Educators
Foundation, for their grant
support of the study
Thank you!
MAP Study Team
•
•
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Gina Carpinito, PharmD
Dale Christensen, PhD
David Williams, RPh
Don Downing, RPh
David Blough, PhD
3
Goals for learning…
• Describe the specific aims of the
Medication Adherence Program (MAP)
Study in Washington State
• Explain the MAP protocol for DM
medication self-management support
• List the primary study findings
– effect of the MAP intervention on DM
medication adherence
– key interventions to facilitate resolution
of self-management challenges
• Discuss study conclusions and next steps
Taking Medications is a
Challenge!
• Adherence to prescribed DM therapy is not ideal:
– Retrospective studies: 31-87% adherence
– Prospective studies: 53-98% adherence
– General literature: 36-85% with better
adherence to insulin
• 80% adherence would mean missing a refill by 6
or more days for a 30 day supply
• Missed refills may flag an adherence difficulty
* Diabetes Educator.2007;33(6)
The challenges
1. Regimen complexity
2. Dosing frequency greater than twice
daily
3. Remembering doses and refills
4. Depression
5. Adverse effects or fearing them
6. Understanding the regimen
7. Belief and confidence in therapy
8. Cost
9. Ability to read the prescription label
Diabetes Educator.2007;33(6)
MAP Study
• Specific aims
– To identify medication self-care
challenges for people with diabetes
– To improve medication self-care for
patients with diabetes
• Study Hypothesis
– A personal, diabetes-care focused call
by the pharmacist in follow-up to a
missed diabetes prescription refill will
improve adherence
Map Study
 Study Design: Randomized, controlled trial,
N=265
◦ 4 participating Safeway pharmacies
 120 MAP intervention patients
 145 control (no-intervention, usual pharmacy care)
patients
 Intervention:
◦ Personal telephone call from pharmacist to patient
who missed an oral DM Rx refill by 6 or more
days.
◦ Call used to address medication self-management
challenges and to promote optimal diabetes care
MAP Call Script
• “Hello. This is (name), your Safeway
pharmacist. I am calling to check in and
see how you are doing with your diabetes
management (discussion Q&A)
• I noticed that you did not refill your (drug
name) this month. Would you like me to
refill it now? Was there a reason that you
didn’t refill it?”
– Subsequent discussion allows for
initiation of intervention actions
Case example…
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Judy is a 67 year old, overweight female with type 2 DM, HTN, painful
neuropathy, and high cholesterol who is late to refill her glyburide and
metformin by 6 days
Meds:
– Glyburide 10 mg po BID
– Metformin 1 gm po BID
– Enalapril 40 mg po daily
– Hydrochlorothiazide 25 mg po daily
– Atorvastatin 40 mg po BID
– Gabapentin 800 mg TID
A call to Judy reveals
– “yes, I take my pills every day but I don’t have any refills left on
the prescriptions. I thought I needed new prescriptions from my
doctor but I haven’t been able to make an appointment yet”
Pharmacy note:
– blood pressure last month 146/92 mmHg
– blood glucose last month 218 mg/dL fasting
– log book: fasting glucose last two weeks all above 200 mg/dL
The intervention
 The pharmacist offered to call Judy’s physician for
refill authorization and encouraged her to come in
the same day to minimize gap in therapy
 Judy was instructed to call the pharmacy for future
refill needs and they will contact the doctor for
authorization
 Encouragement of her continued use of the
medicine was provided
 Referral to provider for diabetes check up
recommended due to recent bp and glucose
results
MAP Study: Analysis
 Question 1: What services did pharmacists
perform, and what were their views about this
added service?
 Question 2: Did the intervention improve DM
medication adherence?
 Adherence to specific medications
 “medication possession ratio” or “MPR”
==============================
 Question 3: What were the predictors of poor
adherence prior to the intervention?
 Question 4: What factors contributed most to the
change in MPR in the 12 month follow-up period?
MAP Study: Baseline
Characteristic
Control (N=145)
Intervention (N=120)
p value
Age (years (SD))
61 (13)
65 (13)
0.015
% female
50.3
53.8
NS
# different Rxs/12
months
56.4 (42)
59.7 (37)
NS
% insulin use
23
23
NS
Medication
complexity Score*
23.4
23.9
NS
MPR DM meds,
12 months pre
0.84
0.86
NS
Refill gap (max)
22.7
22.3
NS
% MPR >0.8
65.2
74.4
0.029
* Complexity score=# unique meds x mean #doses per day
Baseline Medication
Self-Management Problems
Problem reported by patients
(N=119)
Frequency (% of sample)
Difficulty with taking DM medication
32 (27)
- remembering dose
29 (24)
- reading Rx label
6 (5)
- side effects
6 (5)
- hypoglycemia
5 (4)
- gastrointestinal upset
5 (4)
Forget to order refills
31 (26)
Forget to pick up refills
9 (8)
Question 1:
What services did pharmacists
perform, and what were their
views about this added service?
Actions
Intervention Characteristics
Mean (SD)
# visits per subject
3.4 (2.4)
Time on calls with subject (minutes)
12.6 (10.7)
Actions
# subjects (%)
DM Education
42 (35)
Adherence Support
48 (40)
Optimize regimen through consultation
with prescriber
7 (6)
Economic adjustment (e.g. changed to
generic)
3 (3)
Pharmacists Impressions (N=7)
Question
Yes
No
Maybe
Was a report on missed refills
helpful?
7
0
0
Was call focused on DM needs?
7 (reported as
DM med ed or
DM care)
0
0
Did you feel prepared to answer
questions about DM ?
6
1
0
Would a CDE have been helpful
to your patients?
4
1 – not
practical in
retail setting
2 – patients not
at readiness
level
Was the $10 reimbursement per
call sufficient?
6
0
1
If a report were made available
after the study, would you use it?
4
2, not enough
time to call
1
Question 2:
Did the intervention improve DM
medication adherence?
Medication Possession Ratio (MPR)
0.9
0.9
p=0.012
0.88
0.86
0.84
MPR Pre
0.86
NS
0.84
MPR Post
0.82
0.82
0.8
0.78
Control
Intervention
independent t-test
Improved for
intervention over 12
months (p=0.012).
Control change was
not significant.
Is this change in MPR meaningful?
0.04
0.03
MPR Change
0.02
0.01
0
Yes – the change in
MPR for intervention
was significant as
Between Group Comparison of MPR
compared to control
Change
between baseline and
12 months, P=0.004
P=0.004
Control
Intervention
-0.01
-0.02
-0.03
independent t-test difference between differences
Likelihood of oral DM medication
adherence rate above 80%?
• Intervention subjects were 4.77 times
more likely than control subjects to
achieve an oral DM medication adherence
rate greater than 80% during the 12
month intervention follow-up period
Effect
Odds Ratio
95% Confidence
Limits
Intervention
versus Control
4.77
1.996-11.403
* Logistic regression model included demographic, medication,
and baseline adherence variables
Predictors of MPR improvement during the 12
month post period among STUDY patients
• The regression model which included demographic
variables, regimen complexity, and prior oral DM 12
month adherence measures, explained 70% of the
change in MPR scores during the post period.
• Statistically significant predictors of MPR change:
– Low MPR during the prior period (p<0.0001)
– Less resistance to taking meds (p=0.04)
– Less time needed with the pharmacist (p=0.001)
MAP Study: Lessons Learned
• Pharmacies performing the most interventions were those who
integrated late refill messages into the daily dispensing workflow
• Days late for refills is an easy but imprecise indicator of
adherence problems, as it generates false + signals if drugs
were obtained from other sources
•
Key reasons patients give for sub-optimal adherence:
– forgot to refill prescriptions
– forgot to take doses of medications.
• Challenges in optimizing pharmacy-based DM interventions:
• Patients who do not pick up their own medication refills
• Patients using both community and mail order pharmacies
• Patients using multiple physicians for diabetes care
Conclusions
Because adults with DM visit pharmacies more often than they visit any
other health professional, it is believed that there is an untapped
opportunity for pharmacists to provide self-management education and
support for medications. A community pharmacy-based medication
adherence service for DM patients based on late refill alerts is feasible
with adequate training and incentives.
 This study shows that
 a brief telephone follow-up by pharmacists in response to missed
refills improves DM medication adherence
 individuals with low prior adherence and those who are not resistant
to using medications will have the greatest impact on adherence
from the intervention
 Individuals who require more time may not be as responsive to the
intervention
 Effective interventions involved:
◦
Patient education
◦
Adherence support – integrating dosing with ADLs
◦
Advice regarding prevention of side effects
Questions?