Fei Yu, MS

 of this 2-part series provided an overview of the appointment-based model (ABM) for community pharmacies and described how the model increases operational efficiency, freeing up resources for pharmacy staff to perform numerous clinical services. Also discussed were ways in which the ABM can reveal nonadherence in patients and a few specialized populations pharmacists may be able to help overcome unique challenges in appropriate medication use.

There is a reasonable body of research on many of the diverse causes of medication nonadherence. However, there are much fewer data on the effectiveness of various interventions. There is even less research on determining which segments of the patient population are most receptive to interventions and, therefore, more likely to change their behaviors to yield positive outcomes. This is an exciting new area to explore because busy community pharmacies must focus their efforts on patients for whom they can yield the greatest positive impact, improving quality and maximizing their return on resource investment.

Previous research in medication nonadherence has demonstrated that patients who were new to a long-term therapy medication class, across several different chronic conditions, were more likely to discontinue their medication than patients who had prior experience with that same long-term medication class. Ateb has taken these findings a step further, researching the impact of adherence when patients have their first encounter with a medication for their first chronic condition, or initial exposure to chronic therapy (IECT). For this unique patient population, the many barriers to adherence come to a point, leading to a multifactorial view of potential nonadherence. Some of the most significant barriers include the following: lack of understanding of the medication or condition, the asymptomatic nature of certain chronic conditions at diagnosis (eg, hypercholesterolemia, hypertension), unexpected medication adverse effects (AEs), and patient denial of their condition and of the need for lifelong commitment to treatment.

The premise of this original research was based on the theory that patients’ behavior toward their chronic condition and medication is largely formed early in their treatment. Patients’ acceptance, or lack thereof, and subsequent medication and treatment adherence becomes ingrained or “hardwired” after this initial encounter, and this shapes their future behavior, establishing their patterns of medication adherence.

A random sample of de-identified patient data was studied across 11 chronic conditions: osteoporosis, breast cancer, hyperlipidemia, depression and anxiety, diabetes, hypertension, psychiatric conditions (other than depression), respiratory disease, rheumatoid arthritis, gastrointestinal conditions, and thyroid disease. The distribution of patients among these chronic diseases is depicted in Figure 1.

Initial exposure to long-term therapy was studied for 28 months in 206,515 patients. Initial exposure to long-term therapy was defined as not having received any medication for the 11 long-term conditions within the previous 12 months.

 Patients’ prescription behavior was monitored for a subsequent 12 months after the first dispensing date. Across all 11 chronic conditions, the aggregate medication discontinuation rate for patients with IECT was 53% higher than for patients who had previous experience with a medication in any of the 11 conditions.

Figure 2 represents a graphical representation of the data:

Hypertension was the most common first chronic disease encountered by the patients who were studied. The disease’s prevalence and largely benign manifestations—patients are largely asymptomatic, particularly at diagnosis&mdash;make it a particularly attractive chronic disease state for pharmacies to target in regard to patients with IECT. Additionally, many community pharmacies are equipped with blood pressure cuffs, allowing quick and convenient monitoring of disease control, which presents the pharmacist with opportunities to reinforce the benefits of medication adherence and educate the patient about the risks of nonadherent medication behavior.

Poor medication adherence has been identified as a major factor contributing to uncontrolled hypertension

 for several reasons. There are no immediate physical symptoms experienced by patients as a result of missing a dose of medication. In contrast to this are patients being treated for conditions such as epilepsy or asthma, in which nonadherence manifests as symptomatic disease and noticeable discomfort. Although short-term effects of uncontrolled hypertension are difficult to notice, the long-term effects are significant, with stroke, myocardial infarction, and kidney failure being major contributors to morbidity and mortality of patients with hypertension.

Additionally, many antihypertensive medications have AEs that may bother patients, leading to a dislike of taking medication and eventual nonadherence or nonpersistence. For instance, the incidence of a dry, nonproductive cough related to the use of an angiotensin-converting enzyme inhibitor has been reported to be as high as 39% in some studies.

 This dry cough usually develops within the first few months of beginning treatment,

 and although it generally resolves on its own, the cough may be bothersome enough that patients stop taking the medication. Incorrect administration of diuretics (ie, taking them at night) can lead to nighttime awakenings and poor-quality sleep. Beta-blockers are associated with a small but significant incidence of reported fatigue, as well as sexual dysfunction.

 Calcium channel blockers and other vasodilators can cause headache, dizziness, or lightheadedness in 10% to 20% of patients.

 Verapamil is unique among antihypertensive agents in that it causes constipation in over 25% of patients.

Other, non—medication-related behavioral barriers, such as patient denial of a condition or fear of mortality, need to be identified, recognized, and addressed. The role of nontraditional pharmacy skills in motivational interviewing can be an asset in patient empathy and encouragement.

Facilitated by the ABM, pharmacies have untapped opportunities to intervene with this patient population. Pharmacists are in an ideal position to educate patients on potential AEs and suggest ways to manage them. Medication adherence can be improved by educating patients on their disease state and AEs, and periodically following up with them during pharmacy visits. This yields improved clinical outcomes for patients and significant direct economic benefits to pharmacies.

In addition to the direct benefits of improved medication adherence, there are incidental benefits of engaging with this population:

		The pharmacy has an opportunity to make a positive first impression. Given the nature of historical patient loyalty to a pharmacy, spending additional time introducing patients to your pharmacy team, your pharmacy and its services, and your store brand can pay long-term dividends.

		Pharmacists can establish an early pharmacist—patient relationship with an “atypical” patient demographic: patients with IECT are typically 10 to 15 years younger than your ordinary multimedication pharmacy patient. Patients with an IECT may not yet have a pharmacy and could be deciding where their family will be getting their future medication and pharmacy services. Especially with supermarket or mass merchant pharmacy clients, this demographic may be more in line with the typical front-store customer. This provides pharmacy with the opportunity to introduce patients to additional store services, such as nutritional counseling and frequent-shopper programs.

We have explored unique aspects involved in providing pharmacy services to patients recently given a diagnosis of hypertension as their first chronic disease. The utilization of analytics to reveal other specialized patient populations affords pharmacy new opportunities to efficiently incorporate patient care services into their workflow. The ABM enables pharmacy to effectively manage resources to meet the ever-changing and growing needs of their patient population.

, is an advanced analyst and patient data modeler at Ateb. She is responsible for leading a team of statistical analysis system developers and business analysts in support of advanced study analyses and statistical design, modeling, and oversight. 

, is director of analytics and pharmacy programs at Ateb. He is responsible for Ateb’s advanced analytics, business intelligence, and reporting strategies and methodologies. 

 is a fourth-year PharmD candidate at the University of North Carolina Eshelman School of Pharmacy, completing an Advanced Pharmacy Practice Experience at Ateb. 

, is a career-long pioneer in innovative community-based clinical pharmacy practice and an executive health care strategist for Ateb.

		Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. 

. 2003;290(2):199-206. doi: 10.1001/jama.290.2.199.

		Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy: a review of the literature and pathophysiology. 

 1992;117(3):234-242. doi: 10.7326/0003-4819-117-3-234.

		Ravid D, Lishner M, Lang R, Ravid M. Angiotensin-converting enzyme inhibitors and cough: a prospective evaluation in hypertension and in congestive heart failure. 

. 1994;34(11):1116-1120. doi: 10.1002/j.1552-4604.1994.tb01989.x.

		Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. 

. 2002;288(3):351-357. doi: 10.1001/jama.288.3.351.

		Pedrinelli R, Dell'omo G, Mariani M. Calcium channel blockers, postural vasoconstriction and dependent oedema in essential hypertension

. 2001;15(7):455-461. doi: 10.1038/sj.jhh.1001201.

		Abernethy DR, Schwartz JB. Calcium-antagonist drugs. 

. 1999;341(19):1447-1457. doi: 10.1056/NEJM199911043411907.

Articles

While there is a reasonable body of research on many of the diverse causes of medication nonadherence, there are much fewer data on the effectiveness of various interventions.

Unique Considerations for Specialized Patient Populations for Pharmacies Utilizing Appointment-Based Care Models: Part 2

Community pharmacy is at an interesting crossroads with respect to its core business model. Ultimately, to remain viable, pharmacy will need to augment its current product-based gross margin with a new service-based value margin that focuses on patient-centered care. Many community pharmacy leaders and early adopters of patient-centered care are incorporating an appointment-based model (ABM) into their pharmacy workflow to efficiently begin this sea change in their core business practice.

Once the ABM is adopted, programs and services, such as medication synchronization, will become manageable and scalable to the dispensing operation. In addition to medication synchronization, many other pharmacy care opportunities can be folded into the ABM, including immunization services, medication therapy management (MTM), medication reconciliation and transitional care, and Medicare Star Rating and Healthcare Effectiveness Data and Information Set measure—focused activities.

Given the vast pool of untapped patient care opportunities, it is paramount that pharmacy resources be invested wisely using evidence-based approaches. Limited pharmacy resources, coupled with the immaturity of current payment models, necessitate that business decisions be driven by data so that new pharmacy programs yield the greatest benefit for the patient population, the community pharmacy, and payers. Analytics plays an integral role in this process; through patient-segmentation analyses, predictive modeling, and outcomes measurement, a pharmacy can monitor and improve the efficiency and cost effectiveness of the delivery of its patient care programs.

In this article, we provide an overview of the ABM and discuss nonadherence in specialized populations. In part 2, we will review a specialized patient population identified through data analytics and detail a use case that demonstrates the benefit of ABM service delivery to this group.

Traditionally, the pharmacy operations model is very reactive: pharmacy staff members accept new prescriptions or refill requests, contact prescribers if necessary, and fill prescription orders. Patients may arrive unexpectedly at the pharmacy to pick up their medications, often several times a month if they are on multiple medications. As a result, several repetitive activities are required to address a single patient’s medication needs.

In order to offer a more sophisticated patient care process, the ABM improves patient adherence while simultaneously increasing dispensing efficiency. The ABM is fully described in 

"Improving Quality Care: The Appointment-Based Model

.” Here, we will provide an overview of the goals and concepts of the ABM. The core of the most common pharmacy application of ABM is medication synchronization. With all of a patient’s long-term medications being refilled on the same day of the month, the pharmacy team realizes several efficiencies in the dispensing process. For instance, multiple prescription renewal requests to prescribers can be performed simultaneously. As a result, a patient may make just 1 trip to the pharmacy each month, thereby reducing the transactional burden on the pharmacy and providing better convenience to that patient, thereby improving his or her satisfaction. Perhaps the single greatest benefit of synchronizing medications within the ABM model, however, is that the ongoing pharmacy and patient dialogue now centers on the complete medication regimen rather than on individual medications, each at different times. This holistic view dramatically shifts the discussion from the use of a specific medication to the overall impact of the medication regimen on the patient’s health.

Continuing the comprehensive discussions theme, the next component of the ABM is the pre-appointment call. Prior to the patient’s monthly appointment, the pharmacy staff contacts the patient to confirm the medications that need to be refilled. This communication affords opportunity for the pharmacy to learn of discontinued medications, recent prescriber visits, or any hospitalizations. Relevant changes to a patient’s medication list can be reviewed and assessed by pharmacy staff, and adherence issues can be easily identified.

The final piece of the ABM is the scheduled appointment day for patients to pick up their prescriptions. Because the pharmacy is aware of when the patient will arrive, the dispensing activities can be performed at any point prior to the patient’s arrival. This allows previously unpredictable workloads to become predictable and manageable. The operational efficiencies gained also allow the pharmacy to provide comprehensive medication reviews, vaccinations, or other MTM services that may benefit patients on their scheduled appointment day. Lastly, if a patient is not ready for their refills, the pharmacy has a perfect opportunity to identify and discuss nonadherence issues with the patient and agree on a plan to resolve them.

Medication adherence or, more appropriately, medication nonadherence, is a dominant underlying theme common to the majority of pharmacy care opportunities that are exposed by the ABM. Studies show that only 1 in 6 patients is able to adhere to prescribed dosage intervals and administration times and almost never miss a prescribed dose. Another 1 in 3 patients adheres satisfactorily, but occasionally omits 1 or more doses or takes an extra dose.

There are several specialized populations in which medication nonadherence may arise due to unique factors specific to that patient group, including the following:

 functional health literacy is defined as the ability to read, understand, and act on health information.

 Because health literacy does not correlate well with years of schooling or someone’s level of education, it can often be difficult to assess.

 decreased visual acuity and impaired manual dexterity may make it difficult to read small print on prescription labels, differentiate between different medications, and open medication bottles.

 may directly impact a patient’s adherence.

 many studies investigating a variety of disease states have found that administration frequencies of 3 times daily and more are significantly associated with decreased adherence.

Complex medication regimens or a large number of concurrent medications:

 studies investigating the link between polypharmacy and adherence typically have unmeasured confounding.

 However, numerous studies show that poorer adherence is often associated with polypharmacy, especially in the elderly.

 the analytics team at Ateb Inc has discovered that patients with a new diagnosis of their first chronic condition are at significantly higher risk for nonadherence to their new long-term medication.

These are just some of the situations in which the efficiencies of the ABM allow a pharmacy to uncover problems related to a patient’s medication therapy and intervene appropriately. In part 2, we will take a closer look at patients who are experiencing their initial exposure to long-term therapy.

In summary, the ABM is able to enhance the interactions between pharmacies and their patients. The unique considerations that apply to certain specialized patient populations further enhance ABM benefits among these groups.

This article is published in collaboration with the 

		Urquhart J. Role of patient compliance in clinical pharmacokinetics: a review of recent research. 

. 1994;27(3):202-215. doi: 10.2165/00003088-199427030-00004.

		Andrus MR, Roth MT. Health literacy: a review. 

. 2002;22(3):282-302. doi: 10.1592/phco.22.5.282.33191.

		Dimatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. 

. 2000;160(14):2101-2107. doi: 10.1001/archinte.160.14.2101.

		Coons SJ, Sheahan SL, Martin SS, Hendricks J, Robbins CA, Johnson JA. Predictors of medication noncompliance in a sample of older adults. 

		Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. 

. 2001;23(8):1296-1310. doi: 10.1016/S0149-2918(01)80109-0.

		Marcum ZA, Gellad WF. Medication adherence to multidrug regimens. 

. 2012;28(2):287-300. doi: 10.1016/j.cger.2012.01.008.

Community pharmacy is at an interesting crossroads with respect to its core business model. 