Statin Refill by Patient Portal Ups Adherence in Diabetes

Miriam E. Tucker

January 09, 2014

Exclusive use of an online portal to refill statin prescriptions both improved drug adherence and reduced LDL-cholesterol levels among patients with diabetes, a new study finds.

The results, from an observational study using data from Kaiser Permanente Northern California's large, integrated health system, were published online December 26 in Medical Care by Urmimala Sarkar, MD, MPH, from the division of general internal medicine at San Francisco General Hospital and the University of California, San Francisco, and colleagues.

The use of online patient portals that allow for scheduling appointments, reviewing test results, ordering prescriptions, and communicating with providers is growing in healthcare settings, Dr. Sarkar and colleagues write.

Patient engagement with portals plays an important role in "meaningful-use" standards and will likely eventually be tied to incentives and penalties for nonuse, they note. Portals may therefore represent a low-cost structural alternative to improve adherence and increase convenience for the patient, lead investigator Andrew J. Karter, PhD, senior investigator at Kaiser Permanente, division of research, and associate director, Center for Diabetes Translational Research, told Medscape Medical News.

"Individual-level interventions to improve people's adherence are notoriously expensive and often fail," said Dr. Karter.

"There's no question that the option of online ordering of refills is much more convenient for the patient than standing in line at a brick-and-mortar pharmacy," he observed. "Online ordering also likely translates into cost savings for pharmacy operations. So, along with the potential benefits for medications and clinical outcomes, it's a win-win."

Study Designed to Tackle Selection Bias

Previous studies have demonstrated improved process and outcome measures with portal use among patients with diabetes and other chronic conditions, but these may have been confounded by selection bias — that is, patients who choose to use computers are likely to be different in other ways from those who don't.

The current study addressed that problem by only including 17,760 diabetes patients prescribed statins who were already using at least 1 function of the patient portal. They were divided into 3 groups: 3287 who used the portal exclusively when ordering statin prescriptions and refills, 5418 who used the portal occasionally to order prescriptions but also used other methods, such as in person at the pharmacy or by telephone, and 9055 who used at least one of the portal's other functions, such as scheduling appointments or emailing the doctor, but never for ordering prescriptions (reference group).

"In observational research, we always worry about an imbalance in the reference group. But if you compare the people who use the portal to refill with people who are using the portal for other purposes, [the latter] is a much more similar computer-using and engaged control group," Dr. Karter told Medscape Medical News.

Adherence to statins was calculated based on the patients' supply ordering records, with "nonadherent" defined as having a 20% or more time gap during which they had no dispensed statin pills. Adherence was also gauged by measuring LDL-cholesterol levels as a secondary outcome among 3887 of the patients who were nonadherent at baseline.

The follow-up time was 2 refill cycles following initiation of portal use (with or without the refill function), which typically would be about 100 days each (about 6 months) but longer for those with dispensing gaps (ie, who were nonadherent).

Nonadherence Drops by 6% Among Exclusive Users

The prevalence of nonadherence did not change following initiation of portal use among those who didn't use the refill function. In contrast, nonadherence decreased from 26% to 24% among the occasional refill users (P = .01) and from 22% to 15% (P < .001) among those who always ordered prescriptions through the portal.

After adjustment for potential confounders, including baseline medication adherence, age, sex, race, and number of medications and outpatient visits, nonadherence among the exclusive users of the refill function dropped by 6% compared with the nonuser reference group. Similar improvements were not seen among the occasional users, Dr. Sarkar and colleagues report.

And among the group that was nonadherent to statins at baseline, there was a 6% drop in the prevalence of poor LDL-cholesterol control (100 mg/dL or above) after initiation of the refill function compared with the reference group. And again, the occasional users didn't differ from the nonusers.

"In fact, people's LDL control got better. We were surprised that a simple thing like starting to refill their meds online was associated with those improvements," Dr. Karter commented.

"Modest" Effect Worth Trying, but Not Suitable for All

He acknowledged that the effect was "modest" but noted that patient portals are a low-cost structural intervention with very little downside. "For the system it's a good deal, for the patient it's a good deal because it's easier and more convenient, and it turns out to be modestly beneficial in terms of adherence and clinical control. It's a different way of improving healthcare operations and patient outcomes without breaking the bank."

He advised physicians who work in systems that use portals to make sure patients are aware of the refill option and perhaps offer technical support — by a nurse or other staff member — to those who might have difficulty using it.

But he cautioned that patients shouldn't be pressured into online refills. "These kinds of things don't work for everyone… In medicine, it's important that as we create these innovative approaches to delivering care that we make sure the old ones don't just disappear. If you switch to only using online refills, there may be many people who will fall through the cracks."

On the other hand, "You can offer a nice, more convenient option to those who don't want to stand in line or have a hard time getting to the pharmacy."

The authors have reported no relevant financial relationships.

Med Care. Published online December 26, 2013. Abstract

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