A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes
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Cohere Health, Boston, MA, USA; 2University of Hawaii at Manoa, Honolulu, HI, USA; 3Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA; 4University of California, Los Angeles, Los Angeles, CA, USA; 5Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; 6School of Medicine, University of California, Davis, Sacramento, CA, USA; 7University of California, Berkeley, Berkeley, CA, USA.
BACKGROUND: Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no largescale intervention studies have assessed the effect of encouraging MOP use on medication adherence. OBJECTIVE: To assess an intervention to encourage MOP services to increase its use and medication adherence. DESIGN: Randomized encouragement trial. PATIENTS: 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. INTERVENTION: Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. MEASUREMENTS: We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicitystratified analysis. RESULTS: During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. CONCLUSION: This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider
Received March 31, 2020 Accepted September 10, 2020
outreach interventions to actively promote MOP use among diabetes patients. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT02621476 KEY WORDS: diabetes; mail order pharmacy; medication adherence; encouragement trial.
Abbreviations SES KP KPNC KPHI HPHC PDC IVR CVD
socioeconomic status Kaiser Permanente Kaiser Permanente Northern California Kaiser Permanente Hawaii Harvard Pilgrim Health Care proportion of days covered automated phone call cardiovascular disease
J Gen Intern Med DOI: 10.1007/s11606-020-06237-8 © Society of General
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