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

Part 1 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.¹ 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—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 hypertension² 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.³ This dry cough usually develops within the first few months of beginning treatment,⁴ 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.⁵ Calcium channel blockers and other vasodilators can cause headache, dizziness, or lightheadedness in 10% to 20% of patients.⁶ Verapamil is unique among antihypertensive agents in that it causes constipation in over 25% of patients.⁷

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.

Fei Yu, MS, 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. Mike Roberts, RPh, MBA, is director of analytics and pharmacy programs at Ateb. He is responsible for Ateb’s advanced analytics, business intelligence, and reporting strategies and methodologies. Eric Shen is a fourth-year PharmD candidate at the University of North Carolina Eshelman School of Pharmacy, completing an Advanced Pharmacy Practice Experience at Ateb. Frank Sheppard is President and CEO of Ateb, Inc. Rebecca W. Chater, RPh, MPH, FAPhA, is a career-long pioneer in innovative community-based clinical pharmacy practice and an executive health care strategist for Ateb.

References

• Ateb data on file.
• Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 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. Ann Intern Med. 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. J Clin Pharmacol. 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. JAMA. 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. J Hum Hypertens. 2001;15(7):455-461. doi: 10.1038/sj.jhh.1001201.
• Abernethy DR, Schwartz JB. Calcium-antagonist drugs. N Engl J Med. 1999;341(19):1447-1457. doi: 10.1056/NEJM199911043411907.