Mail-Order Pharmacy Reduces Racial Disparities in Adherence to BP Meds

December 13, 2012

OAKLAND, California — Making prescription refills more affordable and easier to obtain may improve adherence to antihypertensive medication, particularly among certain ethnic groups that currently lag behind in terms of compliance, new research shows [1].

"What is new here is that we really did focus on factors we consider to be modifiable through health-system intervention," lead author Dr Alyce S Adams (Kaiser Permanente Division of Research, Oakland, CA) told heartwire . She and her colleagues report their findings in a paper published online December 10, 2012 in the Archives of Internal Medicine.

 
When we looked at race and added in these issues of copay and mail order pharmacy, we found the difference between blacks and whites in particular--but also between Hispanics and whites--narrowed.
 

"We found that health-system factors such as medication copay and the use of mail-order pharmacy were both associated with better adherence for all races and ethnicities," she explains. "And when we looked at race, controlling for clinical factors, and added in these issues of copay and mail-order pharmacy, we found the difference between blacks and whites in particular--but also between Hispanics and whites--narrowed. So it's equally beneficial across [racial] groups, and if we can get people to sign up for it we have a better shot at getting them to comply with their medication.

"What's encouraging is that we've seen so [many] saying these ethnic differences are persistent and we don't know what to do about them, and these are some very specific concrete things that we can look into," she observes.

Nonwhites More Likely to Be Nonpersistent and Nonadherent to Meds

Adams and colleagues used a hypertension registry at Kaiser Permanente Northern California to conduct a retrospective study of 44 167 adults with high blood pressure who were new users of antihypertensive therapy in 2008. Using multivariate logistic regression analysis, they modeled the relationships between race/ethnicity, specific health-system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% days covered during the first 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors.

 
We've seen so much saying these ethnic differences are persistent and we don't know what to do about them, and these are some very specific concrete things that we can look into.
 

"Everyone had insurance, so the first hurdle of access was taken care of," Adams notes.

More than 30% of patients were nonpersistent early, and one in five was nonadherent to therapy; nonwhites were more likely to exhibit both types of behavior compared with whites. After multivariate adjustment for sociodemographic, clinical, and health-system factors, blacks were 56% more likely than whites to demonstrate early nonpersistence, Asians 40% more likely, and Hispanics 46% more likely. Corresponding figures for nonadherence were 55%, 13% and 46%.

Of note, racial and ethnic differences in nonadherence were appreciably attenuated when medication copayment and mail-order pharmacy were accounted for in the models. "Medication copay mattered for everybody, as did mail-order pharmacy," Adams says.

More Research Needed on How Mail-Order Pharmacy Affects Adherence

She explained, however, that copays differed between individuals, depending on their exact health plans and a number of other variables, but for the most part the actual cost saving was small.

"But it may be due to the combination of reduced copay and convenience, not having to take that extra step of coming into the pharmacy for medication, that might have been the incentive for people to sign up," she noted.

Nevertheless, more research is needed to explore the specific mechanisms by which use of mail-order pharmacy may influence adherence across diverse healthcare settings, she and her colleagues note.

 
Mail-order pharmacy may not be enough if it's not done in the context of having those supports in place to help you with other aspects of self-management.
 

"We are not really sure why some people sign up [for mail-order pharmacy] and some don't," she told heartwire . "Some of the suggestions that have been made include lack of awareness that it exists, concerns about receiving medications in the post--either privacy concerns or concerns that people don’t have a safe place where the post office can leave a package like that. Those are just two possibilities, but we don't really know, and it's something we need to understand."

And she stresses, "mail-order pharmacy is so different depending on the setting. Here we have an engaged team of people focused on hypertension reduction, but it may not work the same for someone who is not connected to an integrated healthcare system. So that is an important distinction to make. Mail-order pharmacy may not be enough if it's not done in the context of having those supports in place to help you with other aspects of self-management."

The authors report that they have no disclosures.

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