Rebecca W. Chater, RPh, MPH, FAPhA

For decades, community pharmacists have been seeking new models of compensation for clinical services, especially as the training they receive has shifted towards a focus on patient care, and in-depth clinical decision-making. These readily available health care professionals have the potential to play a critical role in the care of the patients they see every month, but widespread change from a focus on dispensing has yet to occur.

The meticulous and time-intensive nature of dispensing a high volume of prescriptions every day takes too much of the pharmacist’s time, yet prescription volume remains the main revenue driver. Further, even if pharmacists had the time, their access to usable patient data is very limited, making it difficult to know which patients to focus on, or how to best care for them. Finally, and most critically, payers and health plans have been traditionally unwilling to pay pharmacists enough to make it a sound business decision for them to spend a significant amount of time caring for patients.

Overall payer hesitation appears unrelated to the need for proof of pharmacists’ value in managing chronic disease. In fact, this body of evidence has grown so large it is hard to refute.

 The main impediment is scalability—if payments for patient care services were implemented at scale, would pharmacists across the country collectively have the ability to change their day-to-day workflow, spend time with patients, and manage medications for populations the way they are trained? While it would be a disruptive change in the United States’ primary care delivery model, there exists enormous potential for pharmacists to mitigate the burden of chronic disease&mdash;the largest driver of morbidity, mortality, and cost in US health care (~96-99% of Medicare spending).

In recent years, there has been significant progress to improve the efficiency of dispensing activities through automation, theoretically giving pharmacists more time to perform clinical activities. The appointment-based model has gained traction as a way for pharmacies to transition their care process to a more proactive approach. There have also been significant grassroots efforts, such as the Community Pharmacy Enhanced Services Network (CPESN), to increase the level of service expected from a community pharmacy, particularly for independents and small chains. With these advancements, in a time where many pharmacies are desperately in search of new revenue channels, due to shrinking dispensing margins, perhaps pharmacies are willing to accept the risk of adopting a new care model in their practices.  

The emergence of a new Medicare Advantage plan, Troy Medicare, offers much needed momentum to drive pharmacists’ services. Troy’s model puts pharmacists in the driver’s seat of chronic care, namely by including per-member-per-month payments of $30-$50 to pharmacies that fill prescriptions and provide pharmacy services for their members. Troy will also provide technology that enables pharmacists to have a clear view into patients’ healthcare history, as well as interoperable communication of pharmacy care plans (eCare Plan) between healthcare settings. Through these solutions and a pharmacy-friendly reimbursement model that uses NADAC pricing, imposes no DIR fees, and provides flat dispensing fees, Troy hopes to increase transparency and support pharmacies as a business. More broadly, this model intends to leverage pharmacists’ expertise as chronic care managers in order to improve seniors’ outcomes and lower total cost of care.

As a first of its kind, Troy Medicare has emerged at an opportune time, offering financial flexibility that pharmacists and pharmacies have been seeking. Service-based revenue will enable more pharmacies to invest in needed technology, and become much more invested in care delivery. Pharmacists’ ability to regularly and meaningfully engage with patients to improve their care is not only more gratifying for pharmacists, it is a lower cost option for high quality chronic disease management.

Nonoptimized medications are an immense driver of avoidable cost in US health care (>$500 billion/year)

, and the pharmacist’s training, knowledge, and skill are precisely oriented to the management of complex medication regimens for patients with chronic disease, more so than any other health care professional, including physicians. Perhaps we are approaching pharmacy’s perfect storm—a convergence of factors that will serve as a catalyst for societal change in the way chronic medication management is delivered.

As outcomes-based payments, and quality measures continue to strongly influence provider reimbursement, community pharmacies positioned as integral members of the health care team will become indispensable. Troy’s model provides an ideal environment for this transition to reach critical mass.

By simply facilitating a model in which pharmacists can focus less on filling prescriptions, and more on filling their intended role, reimbursement models like Troy’s could be the force needed to pull the linchpin in pharmacy’s long-awaited disruption.

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Articles

The emergence of a new Medicare Advantage plan, Troy Medicare, offers much needed momentum to drive pharmacists’ services.

Payment for Pharmacists’ Care: Pulling the Linchpin

Over the past several years, medicinal cannabis has become a focus of research and legislation, specifically regarding cannabidiol (CBD) oils and other CBD products. CBD is one of the most popular types of cannabinoids, and has been shown to reduce inflammation, convulsions, anxiety, and nausea.

Chain pharmacies, including Walgreens and CVS, have decided to sell CBD products in their stores.

 The projected retail sales of CBD products are expected to reach $1.9 billion by 2020.

 Legislation regarding CBD products is evolving slowly, in attempt to catch up to this current movement.

CBD derived from any cannabis source was previously a Schedule I controlled substance; therefore, the current research of CBD was limited due to the Controlled Substances Act (CSA) formally making it illegal to cultivate, possess, sale, and distribute CBD. Under this law, researchers interested in studying CBD were required to register with the DEA and provide additional information, such as their qualifications, research protocol, and the institution where the research will take place.

The 2014 Farm Bill was subsequently signed into law, which differentiated industrial hemp from marijuana, and authorized industrial hemp research by institutions of higher education or departments of agriculture in states where hemp cultivation was legalized.

 Later, the 2018 Farm Bill removed hemp from the CSA, paving the way for the legal cultivation, possession, sale, and distribution of hemp, thus streamlining research on hemp-derivatives, including CBD, and speeding up the development of new drugs.

Hemp is regarded by the federal government as cannabis containing no more than 0.3% THC, which means that federally legal CBD, which must be derived from hemp or other lawful source, shall contain no more than 0.3% THC.

CBD, when derived from marijuana, or “all parts” of the cannabis plant, remains a Schedule I substance.

 The 2018 Farm Bill also explicitly preserved the FDA’s authority to regulate any products containing hemp-derivatives under the U.S. Federal Food, Drug, and Cosmetic Act  (FDCA). FDA has not approved the use of CBD as a dietary supplement or food additive.

Dr. Alex Capano, Chief Science Officer for Ananda, and a doctoral candidate focused on cannabinoid science, believes that CBD has many uses within the medical treatment realm. Among these include adjunctive therapy for patients on opioids to help them titrate down, pain management, and reducing withdrawal symptoms for narcotic users.

 Furthermore, Capano stated that a potential issue with CBD containing 0.3% THC or less includes drug testing for employers.

Some manufacturers are responding to the market demand by producing and marketing CBD that is THC-free. Even in this case, according to Capano, “there is still possibly an issue with drug testing due to CBD reactivity and false-positives. In addition, the THC-free CBD products are believed to have less therapeutic potential.”

With greater patient access to CBD, pharmacists will need to be prepared to address potential drug interactions to help patients use these products safely. The FDA has issued numerous warning letters instructing various manufacturers to halt production of OTC CBD products since 2016, due to significant discrepancies existing between the tested contents of products and strengths listed on the product labels. As some products were found to contain no trace of CBD compounds during quality testing, widespread mislabeling can easily occur in the absence of strict FDA enforcement.

Furthermore, according to Capano, there is no standard production method among CBD manufacturers, which can lead to impurities being introduced into products. Therefore, microbiological, pesticide, and heavy metal contamination can lead to harmful effects. These risks can be mitigated by patients obtaining CBD products from reliable sources, such as pharmacies that have vetted vendors as trusted CBD suppliers.

Regarding interactions, in vitro studies have illustrated multiple potential drug interactions for CBD. The lack of standardized products somewhat limits the ability to make definitive statements from available research, but there is evidence that CBD is an inhibitor of many CYP450 enzymes including 2D6, 3A4, and 3A5, as well as a potent p-glycoprotein (P-gp) inhibitor.

 Since these are common enzymes of drug metabolism, and with the widespread adoption of CBD oil use by chronic pain patients, there exists a high potential for drug-drug interactions and safety concerns.

Research also suggests CBD use enhances the effect of opiates, and exhibits other interactions with barbiturates, fluoxetine, sedatives, and antihistamines, as well as having synergistic effects with alcohol.

Community pharmacists are well-positioned to intervene clinically at the forefront of this health culture trend. While OTC products appear safe to many consumers, FDA warning letters to numerous manufacturers suggest otherwise.

Pharmacists are patient advocates to protect against adverse outcomes. They can assist with advising patients who present with quality concerns to use CBD products that provide certificates of analyses, and catch significant drug interactions before they occur. As such, it is important for pharmacists to stay abreast of ongoing research developments regarding CBD products. Staying current with emerging literature and evidence-based research on this topic is the best way for pharmacists to ensure they are continuing to provide the most competent and comprehensive care for their patients.

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Sec. 7606 of the farm bill authorized hemp research and pilot programs. https://www.votehemp.com/laws-and-legislation/federal-legislation/sec-7606-of-the-farm-bill/. Accessed June 12, 2019.

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Hudak, J. The farm bill, hemp legalization and the status of CBD: An explainer. https://www.brookings.edu/blog/fixgov/2018/12/14/the-farm-bill-hemp-and-cbd-explainer/. Published December 14, 2018. Accessed June 12, 2019.

FDA Regulation of Cannabis and Cannabis-Derived Products: Questions and Answers. FDA. https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#farmbill. Updated: April 2, 2019. Accessed September 5, 2019.

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Pharmacists can assist with advising patients who present with quality concerns to use CBD products that provide certificates of analyses, and catch significant drug interactions before they occur.

Cannabidiol Products' Impact on Pharmacist-Provided Medication Management

Medication nonadherence is a major cause of morbidity, especially in elderly patients. Approximately 10% of hospitalizations may be a result of medication nonadherence.

It is not only an individual patient’s health problem, but also contributes up to $300 billion of avoidable healthcare costs in the United States (US) and up to 30% of wasteful spending.

By 2030, 20% of the US population will be aged 65 years or older.

 Patients over 60 years of age consume 50% of dispensed prescription drugs.

 As the population continues to age, chronic disease becomes more prevalent. This translates to an increase in the volume and complexity of medication regimens, increasing the risk for nonadherence. Other factors increasing the likelihood of nonadherence in the elderly include adverse drug reactions that come with polypharmacy, decreased visibility and motor dexterity, and decreased autonomy.

A study assessing the link between potentially inappropriate medicines and avoidable adverse drug events in patients 65 years or older found 68.9% of hospital admissions were avoidable or potentially avoidable due to inappropriate medications.

On average, older adults take 6-8 medications, typically due to multiple chronic diseases placing them at increased risk for polypharmacy. One in 5 older adults receives inappropriate medications, while 9% take 2 medications from the same drug class.

 Polypharmacy increases the risk of duplicate therapies, adverse drug reactions, drug-drug interactions, and geriatric 'syndromes,' such as urinary incontinence, falls/fractures, and cognitive impairment, all of which may contribute to and exacerbate poor medication adherence.

Pharmacy labels contain a lot of information, typically in a small font, making them difficult to read for elderly patients with visual impairment. Inability to read the labels and understand how to take their medications can lead to incorrect administration, adverse reactions, and ultimately poor adherence. Additionally, elderly patients may experience difficulty opening pill bottles, even non-childproof ones, due to reduced motor dexterity or chronic conditions like arthritis.

Aging patients may be limited in their ability to move, drive, and get to the pharmacy in time to pick up their refills. This can lead to delayed refills, resulting in nonadherence. Additionally, this may limit their ability to speak with a pharmacist regarding a medication-related problem they are having.

Implementing services in community pharmacies that are tailored to the needs of the older adult population is key to combating nonadherence. As one of the most accessible health care providers and medication experts, pharmacists can optimize a patient’s medication regimen in order to minimize polypharmacy and associated adverse drug reactions. Through medication therapy management (MTM), pharmacists can identify duplicate or unnecessary therapies. They can also identify drug-drug interactions and potential side effects, and advise patients on how to alleviate them. MTM provided by pharmacists significantly improves health outcomes, as shown in the recent STOMPP study of diabetes patients receiving MTM where A1C goals were achieved.

Community pharmacies can provide multimed blister packaging to facilitate medication organization and eliminate the need for pill bottles. This packaging uses symbols or colors to indicate the time of the day for each dose, which can help overcome the decreased visual ability that comes with age. Additionally, using blister packs can combat motor dexterity issues associated with opening vials. In the STOMPP study, patients who received multimed blister cards achieved adherence scores greater than 45% above baseline when compared to pill bottles.

A pharmacy with medication synchronization that follows the appointment-based model (ABM) is optimal for older adults with limited access to transportation and decreased autonomy. This system reduces frequent trips to the pharmacy, providing one monthly appointment, based on the patient’s preference, to pick up all medications and meet with the pharmacist. This increases convenience and coordination, improving adherence. In a recent study by Harvard Medical School, patients enrolled in a medication synchronization program had 9% lower rates of hospitalizations and emergency department visits compared to those not enrolled, likely due to the associated improved adherence.

Patient nonadherence to prescribed medications is associated with poor therapeutic outcomes, progression of disease, increased healthcare utilization, and an estimated burden of billions per year in avoidable direct healthcare costs. Medication nonadherence is especially common in older adults. Pharmacies can help overcome this public health concern by providing MTM, multimed packaging, medication synchronization, and utilizing the ABM.

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Medication nonadherence is a major cause of morbidity, especially in elderly patients.

Medication Nonadherence in Older Adults: Patient Engagement Solutions and Pharmacist Impact

Amazon recently announced its entry into pharmacy through the acquisition of PillPack, a service that delivers medications, presorted in adherence packaging, to a patient’s home. The announcement has the pharmacy profession and the pharmaceutical industry debating several questions around the deal’s impact on local pharmacies and the role of the pharmacist in this process. At last estimate, the burden of nonadherence on our healthcare system exceeded $300 billion in direct and indirect costs, with approximately 50% of patients not taking their medications as prescribed, indicating a clear opportunity to mitigate related barriers to improved adherence.

While convenient access to medications certainly aids adherence, and could be facilitated by the PillPack acquisition, the deal stands to disrupt direct pharmacist-to-patient contact and the essential role of the community-based pharmacist within the healthcare continuum. Convenience of medication delivery is not a panacea for resolution of nonadherence and falls woefully short in addressing other critical aspects of addressing medication-related problems including unanticipated medication interactions, gaps in care, cost challenges, lack of patient education, lifestyle incompatibilities, and others.

Rather than focusing on the PillPack acquisition by Amazon as a threat, pharmacists should consider this as an opportunity to reassess the value that they bring—the existing patient care services, tools, and technology that equip them to deliver patient-centric, personalized care. Whether employing data analytics to more efficiently identify needed interventions, adherence packaging, or medication therapy management, pharmacies can enhance their service offerings to differentiate their practices and keep patients at the center of care.

Pharmacists have long differentiated themselves with patients by stepping up to help with the confusion around managing multiple medications, and monitoring health issues. By using technology to streamline patient communications, and offering adherence tools, such as 

, that can be customized to each patient, pharmacists can ensure they are not edged out by the online retailer.

This is especially true when patients experience care transitions. From one care setting to the next, they need the pharmacist as a local resource to help ensure smooth transition, and guide them on their path to better health outcomes. Research has shown that pharmacists are specially qualified to fulfill this role, helping to address concerns, and reduce medication errors that might not always be evident. The one-size-fits-all approach that Amazon is developing circumvents the role of the local pharmacist, and is not designed to meet the individualized needs of patients with unique health concerns.

Enhancing Pharmacy Care for Better Results

As our nation’s most accessible healthcare professionals, pharmacists serve as touchstones of care in communities all across the country, offering patient-centered, personalized, and coordinated care. Emerging data-driven solutions provide pharmacists with tools they need to increase their value through targeted clinical engagement, enabling them to further improve health outcomes, reduce healthcare costs, while offering a level of patient convenience that rivals Amazon-PillPack.

Centralized, actionable data specific to managing patient engagement is essential to improving care while reducing costs across the care continuum. For this reason, healthcare needs a system that not only provides convenience related to medication access—as this Amazon acquisition aims to do&mdash;but also keeps the pharmacist regularly connected to the patient to evaluate medication-related health needs on an ongoing basis, communicating as needed with patient and prescriber regarding medication adherence, potential medication changes or dosage adjustments, side effects, drug interactions, needed vaccinations, and more.

The coming months will reveal changes that result from the Amazon-PillPack deal. In the meantime, pharmacists should take this as an opportunity to amplify their value to further differentiate their practices, ensuring that their role will not be diminished by this new venture. By staying connected to their patients and implementing tools that help to expand their service offerings and improve patient care, today’s pharmacists will reinforce their own essential role in the care continuum, now and in the future.

While convenient access to medications certainly aids adherence, and could be facilitated by the Amazon's recent acquisition of PillPack, the deal stands to disrupt direct pharmacist-to-patient contact, and the essential role of the community-based pharmacist within the healthcare continuum.

How Pharmacists Can Stay at the Forefront of Patient Care in an Evolving Market

Low adherence to prescribed self-administered medication is well documented and presents significant challenges in the treatment of chronic conditions. In developed countries, adherence to long-term therapy is estimated to average 50%.

 Despite more than 4 decades of research regarding the proper measurement of medication adherence (MA), our most widely adopted methods for assessing adherence, Proportion of Days Covered (PDC), Medication Possession Ratio (MPR), and Average Days on Therapy (ADT), all use prescription-refilling patterns as surrogate measures for patient medication-taking behavior.

 This underscores a tremendous need for pharmacists to help patients self-manage adherence beyond the point of obtaining their medications from the pharmacy. Evidence supports multimedication packaging as a primary tool to meet this need.

Forgetting to take a medication is the most frequently patient-reported reason for nonadherence.

 In a survey of over 24,000 adults, 70% reported unintentional non-adherence behaviors, including forgetting to take their medications (62%), running out of medication (37%), and being careless about taking medication (23%).

  Multimed packaging is a highly useful tool for addressing each of these areas of non-intentional nonadherence.

 It provides a convenient method for patients to self-monitor medication consumption, eliminating the need to remember whether a certain dose has been consumed. It also gives both patients and caregivers an immediate visual verification of doses previously removed from the device.

 Further, multimed packaging is especially effective for medications that should be consumed at different times of day, as it eliminates the need decision-making regarding which medications to consume at different times.

 It also mitigates nonadherence by eliminating the need for patients to open multiple containers for each administration.

Additionally, patients favor the ease of opening the blisters, and the capacity of the multimed blister card, which, depending on manufacturer, may accommodate up to a 14-medication regimen.

Multiple studies have documented improved MA over time using multimed packaging. This result is in contrast with MA behavior following most other MA interventions, which generally reveal a pattern of diminished MA over time. A systematic review/meta-analysis that looked at the overall effect of packaging interventions found that blister packs were the most effective of all packaging interventions used, with an overall mean weighted standardized difference effect size of 0.802 compared to that of pill boxes at 0.384. Interventions were found to be more effective when delivered by a pharmacist, 0.782, than interventions without a pharmacist, 0.475.

 Additionally, MA interventions that exclusively used multimed packaging were as effective as interventions that combined packaging with other adherence interventions.

Since medication persistence is necessary for the achievement of desired health outcomes, this is an important benefit of multimed packaging. 

In addition to medication adherence, several studies demonstrated improvement in clinical outcomes associated with multimed blister packaging. The FAME study showed adherence improved from 61.2% to 96.9%, with a reduction in mean systolic blood pressure from 133.3 to 124.4.

Similar results were shown in two studies conducted in 2017 by Bosworth et al. and Tan, et al., both of which found packaging to improve blood pressure due to improved adherence to the medication(s) prescribed.

Pharmacies that have integrated multimed packaging into their practices are seeing positive results in terms of patient satisfaction and quality performance. However, pharmacy adoption of multimed packaging in the U.S., as compared to other countries, represents a clear opportunity. In the U.K., for example, multimed packaging is mainstream, with nearly every pharmacy offering the service. This includes approximately 20% of all patients who receive 4 or more chronic medications.

 Technology and automation offer innovative options for pharmacies who wish to move beyond manual blister packaging, and capture greater efficiency. By automating the multimed packaging process, pharmacy teams are able to dedicate more of their time providing much needed patient care services.

As we prepare for value-based care, and consider ways to improve medication adherence, patient safety, patient loyalty, quality measure performance, and profitability, multimed packaging offers a rewarding, innovative option for pharmacists, support staff, and patients.

Rebecca W. Chater, RPh, MPH, FAPhA, is a career-long pioneer in innovative community-based clinical pharmacy practice. Chater is director of clinical healthcare strategy with Omnicell, Inc., a leading provider of patient engagement solutions, inspired to create safer and more efficient ways to manage medications and supplies across all care settings. Throughout her career, Chater has championed the pharmacist as a medication expert, integral to the healthcare team in optimizing medication use.

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Multimed Packaging Impact on Medication Adherence and Clinical Outcomes 

 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.

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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.