Abstract
Introduction
Adherence to daily medication regimens is crucial in achieving optimum outcomes in chronic diseases. Medication adherence refers to whether patients take their medications as prescribed without missing days of medication. Mounting evidence indicates that nonadherence is quite prevalent 1 and is associated with higher cost of care. 2,3 More than $100 billion is spent each year in avoidable hospitalizations due to medication nonadherence. 2 Furthermore, nonadherence has been associated with increased morbidity and mortality in patients with chronic conditions. 1,3 Such issues are particularly important in the face of rising health care costs.
Previous research has revealed multiple factors that influence adherence to medication. Such factors include out of pocket cost for medications, side effect profile, presence of physical or mental impairment, and presence of symptoms of disease for which medication is being prescribed. 1 Patient factors associated with decreased adherence include younger age, non-white race, and depression. 1 The degree of regimen complexity is of critical importance when discussing adherence. Decreasing complexity of treatment by reducing the frequency of dosing 4 or using fixed dose medication combinations 5 results in improved adherence.
Choudhry et al 6 broadened the concept of complexity by observing that adherence decreased with the more unique pharmacies at which an individual filled and the less “refill consolidation” they had. Refill consolidation refers to the number of medications allowed to be refilled per pharmacy visit. A person who fills fewer of their total prescriptions per pharmacy visit and thus must travel to the pharmacy at a greater frequency has lower refill consolidation.
To our knowledge, no studies have specifically examined the issue of refill consolidation among patients of lower socioeconomic status. Nor has the impact of medication supply limitations imposed by insurance companies been examined as it relates to such issues. The average Medicaid patient is on many prescription medications prescribed by multiple providers. 7 Refills for a given medication must occur in a 30-day cycle, thus requiring patients on multiple medications to refill medicines at different times. We postulated that the degree of regimen complexity, including refill consolidation, would have great impact on adherence in the Medicaid population.
Methods
Patient Selection and Data Collection
Surveys were administered to 50 patients who were seen at the George Washington University Medical Faculty Associates in the Department of Internal Medicine. This was a convenience sample based on arrival of patients to the Department of Medicine clinics on the days of data collection. Patients were approached in the waiting room or examination room prior to the physician entering. A total of 52 patients were approached for participation in the study. Two patients declined involvement for a participation rate of 96%. Only patients on two or more daily prescription medications were included. All patients were insured by Medicaid for the District of Columbia (DC Medicaid). Single individuals were eligible for DC Medicaid in 2012 if they made less than $14,856.10 per year. The institutional review board approved survey was read aloud to each participant in order to minimize variability in response based on reading comprehension.
Survey
Demographic information included age, gender, and race. Thirteen questions were related to pharmacy and medication history. This included the Morisky 8-item survey 8 -10 as a generalized measure of adherence. The 8-item Morisky is a structured 8-item self-reported measure of medication adherence (α reliability = .83). It is composed of the following 8 questions: (1) Do you sometimes forget to take your medicine? (2) Thinking over the past 2 weeks, were there days when you did not take your medicine? (3) Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? (4) When you travel or leave home do you sometimes forget to take your medicine? (5) Did you take all your medicines yesterday? (6) When you feel like your symptoms are under control do you sometimes stop taking your medicine? (7) Do you ever feel hassled about sticking to your treatment plan? (8) How often do you have difficulty remembering to take all of your medicine? Based on responses, subjects are classified as low adherence (score greater than 2), medium adherence (score 1 or 2), or high adherence (score of 0). A 10-item medication consolidation questionnaire was included to assess various aspects of regimen complexity on missed doses of medications. Question type included “yes/no” questions, 5-item Likert-type scale as an indication of level of agreement or disagreement, and open-ended questions asking for discrete numerical responses.
Statistical Analysis
Descriptive statistics (including medians, means and standard errors, frequencies) were used as appropriate to summarize responses to individual survey questions. The association between number of prescribing providers and survey questions assessing number of trips to pharmacy in a given month as well as missed medication dosages due to running out of medications were evaluated using Wilcoxon rank sum test. The association between total number of prescriptions and each of the above factors was also analyzed using Wilcoxon rank sum test. Chi-square analysis was used to assess relationship between level of adherence based on Morisky 8-item scoring system 10 and responses to the 10-item medication consolidation survey. The level of significance was set at <.05.
Results
Survey participation rate was 96%. Patient characteristics are shown in Table 1. Twenty-six (52%) patients had a low adherence score on the Morisky 8-item scoring system, 23 (46%) had medium adherence, and 1 (2%) had high adherence. Thirty-three (66%) had 1 to 2 prescribing providers. Thirty-nine (78%) picked up their medications from a single pharmacy.
Patient Characteristics; Pharmacy, and Medication History.
Responses to refill consolidation survey questions are shown in Table 2. Twenty-six (52%) indicated that they missed a day or more of medication in the past 6 months because they ran out of medication. Twenty-six (52%) indicated that they are required to go to the pharmacy more than once in a given month to keep all of their medications filled. Twenty-two (44%) had been turned away from their pharmacy at some point because 30 days had not elapsed since their last refill. Fourteen (28%) of those who had been turned away from a pharmacy missed a day or more of their medication as a result.
Medication Consolidation Questionnaire.
Twenty-eight (56%) stated that they would miss less medication doses if all of their medications could be refilled on the same day each month. Based on the Wilcoxon rank sums test, there was no significant association between going to the pharmacy greater than once per month and the number of daily prescription medications (P = .76) or with the number of prescribers (P = .22). Those who agreed that refilling prescriptions on different days throughout the month caused them to miss a day or more of medication had significantly higher number of prescriptions (P = .03) and higher number of prescribers (P = .03) than those who did not agree. There was no statistically significant difference between those who had missed doses of medications due to running out of medication and Morisky 8-item adherence score. There was no statistically significant difference between those who missed doses of medication because medications must be refilled on different dates and Morisky adherence score.
Discussion
Our study of a small cohort of DC Medicaid patients demonstrates that this population faces significant challenges in adhering to their medication regimens. The majority of patients had missed a day or more of medication in the past 6 months because they had run out of medication. The majority of the patients also travel to the pharmacy more than once per month in order to refill their medications. In all, 46% stated that they miss doses of medication because their medications must be refilled on different dates. The majority of patients stated that they would miss less doses of their medications if all medications could be refilled once per month. As explained by Choudhry et al, 6 the more medications that must be refilled in a dyssynchronous fashion, the lower the refill consolidation. Thus, this population has poor refill consolidation.
Those patients who endorsed missing doses because refills occur on different dates had significantly higher number of prescriptions and significantly higher number of providers than those who did not agree. Thus, as regimen complexity increased in terms of number of prescriptions and number of prescribers, refill consolidation problems increased. It would make sense that having a higher number of medications and having medications prescribed at different times by multiple providers would result in more trips to the pharmacy in order to keep all medications refilled. Although no control cohort exists, the lower socioeconomic status of Medicaid patients may make multiple trips to the pharmacy each month more difficult than for the larger population of insured patients. This creates a significant barrier to medication adherence in this population.
Interestingly, there was no significant association between those who missed doses of medications due to dyssynchronous refills and the Morisky 8-item adherence scale. This is a population where the majority of patients scored low adherence with only a single patient categorized as high adherence. As only one patient was classified as high adherence, there may not be enough power in this small cohort to find a difference with regard to refill consolidation questions between the medium and low adherence group. Because our questions were directly asking about missed medication doses in relation to refill consolidation issues, we feel that our results represent low refill consolidation associated with decreased adherence in this population.
We would have predicted that patients might have difficulty keeping medications filled when new medications were prescribed, changes occurred in dosage of existing medication, or after discharge from the hospital. Only a small number of subjects indicated these circumstances to be challenging in terms of medication management. We also predicted that difficulty with transportation to the pharmacy would have caused patients to miss doses of medication. Twenty-six percent indicated this to be the case.
This study supports the findings of Choudhry et al 6 that low refill consolidation is associated with decreased adherence. It should be noted that the aforementioned study was a prospective design with a large cohort who filled medication through a particular pharmacy benefit provider. Our study was retrospectively designed with a small cohort of Medicaid patients.
DC Medicaid patients seem to be missing medication doses, in part, because of poor refill consolidation. Given the higher costs of care 2 and higher morbidity and mortality 1 associated with poor adherence, this population would benefit from interventions to improve refill consolidation. Uniform to the DC Medicaid population is a 30-day medication supply limitation. Almost all state Medicaid programs limit the supply of dispensed medication to 30 to 34 days. 11 There are certain instances involving a select few medications where physicians may submit paperwork on behalf of a given patient for a more extended supply. 11 It would make sense that such a limitation would result in greater trips to the pharmacy in order to fill multiple medications prescribed by multiple physicians. If a patient or physician wanted to extend the supply of a given medication by a few days in order for the refill date to align with that of other medications, this would not be possible in the current system. Thus, the DC Medicaid population may face greater challenges than the general population in terms of medication consolidation.
Some have suggested that the consolidation issue can be solved by coordination of medication regimens by physicians. However, this would require significant investment of time and electronic data sharing among practitioners. Each physician a patient visits would have to go through this process. Consolidation performed by a primary care physician often would fall apart on a visit to a specialist if this were not the case. A more realistic solution that has been suggested is that of a “pharmacy home.” In this case, a pharmacist could monitor all medications taken by an individual and make appropriate adjustments in order to consolidate the regimen and minimize trips to the pharmacy. When necessary, the pharmacist could contact the prescribing physician for approval of extending the supply of a medication. The pharmacy would be capable of facilitating early renewals or providing a small supply of an existing prescription for all refills to occur at the same time. For example, a patient starts a 30-day antihypertensive medication with 5 monthly refills as prescribed by his primary care physician and 15 days later sees a cardiologist who prescribes a new anti-arrhythmic medication with a 30-day supply. The pharmacist could check with the primary care physician and extend the first prescription to 45 days (15 additional days) to allow the patient to pick up refills for both medications on the same date in future months. This solution would not only improve refill consolation but may also help with other aspects of regimen complexity such as identifying instances where fixed dose combinations may be appropriate and monitoring for drug interactions.
The Medicaid population would benefit from a policy that allowed for flexibility in medication supplies to improve refill consolidation. This would allow a physician or pharmacist to consider appropriate adjustments and potentially improve adherence in this population. Definitive statements cannot be made in this regard because of lack of a control cohort of patients with other types of insurance. However, it is clear that for this population, the 30-day supply policy only aggravates poor refill consolidation.
Limitations of this study include a relatively small sample size and retrospective design that asks for patients to recall prior experience. Larger sample size with a prospective design based on pharmacy data would be helpful in confirming the findings of this study.
Our analysis suggests that a 30-day medication supply policy for DC Medicaid patients limits medication refill consolidation, thereby aggravating medication nonadherence in a population on multiple medications, with multiple prescribers, and often multiple pharmacies. This population would benefit from a more flexible medication refill policy that increases medication synchronization, thereby decreasing regimen complexity.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Biographies