Adherence to Cardiovascular Meds Suffers When Pharmacies Shut Down for Good

April 26, 2019

Many older patients stop filling their prescriptions for statins, beta blockers, and oral anticoagulants when the pharmacy they typically use closes down, suggests an analysis based on claims data involving almost 60,000 pharmacies in the United States.

Rates of such "nonadherence" to cardiovascular meds rose more sharply for patients with Medicaid prescription coverage, living in rural regions and areas with fewer pharmacies, and relying on independent pharmacies rather than chain stores.

Moreover, some of the biggest rises in nonadherence, based on days covered by filled prescriptions, were seen in patients who were fully adherent to their medications, without other apparent obstacles to having prescriptions filled, for an entire year before their pharmacies closed.

The findings support an independent role for pharmacy closure as a driver of medication nonadherence, "and that it's not only patient-level factors," Dima M. Qato, PharmD, MPH, PhD, University of Illinois at Chicago, told | Medscape Cardiology.

"There's an access component to it that I think often gets overlooked, and we need to think about it from a policy perspective." Although third-party payers and changes to pharmacy practices could also help, it may be that prevention of pharmacy closures is a worthwhile goal for healthcare policy, said Qato, who is lead author on the analysis published April 19 in JAMA Network Open.

Of the 59,375 individual retail pharmacies reporting prescription fulfillment throughout 2011 to 2016, as documented in the IQVIA LRx LifeLink database, 3622, or 6.1%, closed for business during that period.

Of those that closed, 42% had been independent businesses, about 16% were part of pharmacy chains, and the rest were within other businesses, such as grocery or department stores, the group reported.

The researchers assessed medication adherence for patients who filled prescriptions for statins, beta blockers, or oral anticoagulants (the latter either warfarin or newer direct-acting agents) at pharmacies that closed sometime later during the study period.

Those "closure cohorts" for the different medication categories were compared with the remaining "nonclosure" patients, who filled prescriptions at pharmacies that didn't close during the study period, both before and after pharmacy closure.

The closure cohorts consisted of:

  • 92,287 of a total of 3,089,803 (3.0%) patients with prescriptions for statins

  • 64,420 of 2,081,836 (3.1%) patients with beta-blocker prescriptions

  • 11,576 of 377,526 (3.1%) patients with prescriptions for oral anticoagulants

For all three medication categories, the monthly proportion of days covered by filled prescriptions during the 12-month preclosure baseline period was similar for the closure and nonclosure cohorts; it was between 70% and 71% for both.

For all three medication types, adherence fell off right away after pharmacy closures, the group reported. Decreases in the monthly proportion of days covered by filled prescriptions during the first 3 months after closure, compared with the 12-month baseline period, were significant and remained so throughout the 12 months after closure in multivariate analyses.

Decreases in Adherence (Mean Absolute Percentage-Point Reduction) in the 3 Months After Pharmacy Closure, Three Medication Classes
Medication Class For All Patients (%) For Patietns Fully Adherent* at Baseline (%)
Statins 5.90 8.57
β-blockers 5.71 8.07
Oral anticoagulants 5.63 8.37
*≥80% proportion of days covered
P < .001 for all decreases

Significant decreases were observed across most subgroups of patients in the closure cohort, including by type of pharmacy, number of unique prescriptions filled, method of payment or coverage, size of copay, income group, and ethnic group.

Reasons that pharmacies close are varied and complex, but one of them may be the influence of preferred pharmacy provider networks within managed care plans, Qato observed. As she and her colleagues propose, health plans that offer greater flexibility of choice in pharmacy provider might promote greater medication adherence.

Or, the Centers for Medicare & Medicaid Services could require Medicare Part D to include minimum standards for pharmacy reimbursement, with "specific provisions that mandate similar access standards for preferred pharmacies that ensure their stability," she and her colleagues write.

It's in the interest of third-party payers to promote better patient adherence to medications, "and if we're showing that patients are becoming nonadherent because of pharmacy closures, I think it's good financial sense to think about reimbursement rates to plans but also reimbursement rates back to the pharmacy," Qato said.

"If pharmacies were incentivized to stay open, they might stay open," she said, but remaining open would be important to medication adherence for some pharmacies more than others. Priority could be given to pharmacies in regions without many other pharmacy alternatives for patients to fall back on, for example.

Policy officials could view pharmacies "in terms of hierarchies or tiers like we did for critical-access hospitals, and use a similar framework to address the risk of pharmacy closure in certain urban and rural areas. I think that would be an important and good starting point."

Qato pointed to another finding that underscores the importance of communication between patients and their pharmacies with plans to close.

"We found that the decline in adherence was worse for patients that had a refill due within 2 weeks after the store closed," compared with a month or more later, she said. "It suggests that they didn't know about it until they went in to fill it, and it was too late to maintain their regimen."

Instead, pharmacies could let patients know of impending closures a month or two in advance, "and give them options in terms of what they need to ensure their prescriptions are filled," options that aren't an added financial burden, she said. "Informing patients that are affected directly by the closing I think would go a long way in terms of improving adherence."

Qato discloses serving as a consultant to Public Citizen's Health Research Group; disclosures for the other authors are in the report.

JAMA Netw Open. 2019;2:e192606. Full text

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