Encouraging Mail Order Pharmacy Use to Improve Outcomes and Reduce Disparities

 描述（由申请人提供）：糖尿病患者坚持使用有效的心血管疾病（CVD）风险因素药物与改善CVD风险因素控制、减少住院和降低死亡率相关。然而，许多患者对药物的依从性较差，并且在药物依从性方面存在持续的种族/民族和社会经济差异。传统的干预措施，以提高药物依从性的临床试验往往是资源密集型的，并专注于患者层面的障碍，以改变行为。毫不奇怪，这些试验并没有导致可持续的，具有成本效益的方法来提高依从性。迫切需要能够在广泛的卫生保健提供环境中实施、"扩大规模"和持续的卫生系统一级的药物依从性干预措施。通过现有的邮购药店提供有效的处方药可以被认为是一个系统级的方法，以提高获得药物。先前使用观察数据的研究表明，邮购药房的使用与改善对CVD风险因素药物的依从性以及改善CVD风险因素控制相关。尽管有这些证据，尽管邮购药房的使用可能会节省患者和健康计划的成本，但只有不到25%的糖尿病患者使用邮购药房来获得糖尿病药物。非白人和社会经济地位较低的患者中邮购药房的使用率甚至更低。我们建议进行一项随机鼓励试验，以鼓励对心血管疾病危险因素药物依从性差的糖尿病患者使用现有的邮购药房服务，这些患者仅使用3个医疗保健系统中的零售药房：Kaiser Permanente北方加州，哈佛朝圣者和Kaiser Permanente夏威夷。这些综合系统包括大约300，000名具有不同种族/民族和社会经济背景的糖尿病患者。没有邮购药房使用史的患者将被随机分为3组：1）标准化干预，以鼓励邮购使用并提供有关如何获得服务的易于获取的信息; 2）个性化干预，包括标准化干预的组成部分以及针对患者定制的附加信息，具体特征，例如处方方案和通过切换到邮购药房的个性化潜在节省;以及3）常规护理。除了检查干预措施对药物依从性和心血管疾病风险因素控制的影响外，我们还将检查影响干预措施可持续性和传播的因素，评估干预措施对利用率和医疗保健成本的影响，并确定干预措施的影响是否在种族/民族和社会经济亚组中存在差异。这项研究将为开发可持续的系统级方法提供基础，以解决糖尿病患者的药物依从性问题，这些方法可以在各种医疗保健系统中广泛传播和实施。

 DESCRIPTION (provided by applicant): Adherence to effective cardiovascular disease (CVD) risk factor medications is associated with improved CVD risk factor control, fewer hospitalizations, and lower mortality in patients with diabetes. However, many patients are poorly adherent to medications, and there are persistent racial/ethnic and socioeconomic disparities in medication adherence. Traditional clinical trials of interventions to improve medication adherence are often resource-intensive, and focus exclusively on patient-level barriers to behavior change. Unsurprisingly, these trials have not led to sustainable, cost-effective approaches to improve adherence. Health system-level medication adherence interventions that can be implemented, "scaled up," and sustained across a wide range of health care delivery settings are urgently needed. Delivering efficacious prescription drugs through existing mail order pharmacies can be considered a system-level approach to enhancing access to medications. Previous research using observational data has shown that mail order pharmacy use is associated with improved adherence to CVD risk factor medications, and with improved CVD risk factor control. Despite this evidence, and although mail order pharmacy use is potentially cost-saving to both patients and health plans, fewer than 25% of patients with diabetes use the mail order pharmacy to obtain their diabetes medications. Mail order pharmacy use is even lower among non- whites and patients with lower socioeconomic status. We propose a randomized encouragement trial to encourage use of existing mail order pharmacy services among diabetes patients with poor adherence to CVD risk factor medications and who only use retail pharmacies in 3 health care systems: Kaiser Permanente Northern California, Harvard Pilgrim, and Kaiser Permanente Hawaii. These combined systems include approximately 300,000 patients with diabetes with diverse racial/ethnic and socioeconomic backgrounds. Patients with no history of mail order pharmacy use will be randomized into 3 arms: 1) a standardized intervention to encourage mail order use and provide easily accessible information on how to access the service; 2) a personalized intervention that includes components of the standardized intervention as well as additional information tailored to patient-specific characteristics such as prescription regimens and individualized potential savings by switching to the mail order pharmacy; and 3) usual care. In addition to examining the impact of the intervention on medication adherence and CVD risk factor control, we will examine factors affecting the sustainability and dissemination of the intervention, assess the intervention's impact on utilization and health care costs, and determine whether the intervention's impact differs across racial/ethnic and socioeconomic subgroups. This research will provide a foundation for developing sustainable, system-level approaches to addressing medication adherence in diabetes patients that can be widely disseminated and implemented across a diverse array of health care systems.