title: A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan.
abstract: BACKGROUND
  Patients with comorbid hypertension (HTN) and diabetes mellitus (DM) are at a high risk of developing macrovascular and microvascular complications of DM. Controlling high blood pressure can greatly reduce these complications. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with both DM and HTN by the American Diabetes Association guidelines, and their benefit and efficacy in reducing macrovascular and microvascular complications of DM have been well documented. Poor adherence, however, remains a significant barrier to achieving full effectiveness and optimal outcomes.
  
  
  OBJECTIVE
  To examine the effect of a brief pharmacist telephone intervention in identifying adherence barriers and improving adherence to ACEI/ARB medications among nonadherent patients with comorbid HTN and DM who are enrolled in a Medicare Advantage plan.
  
  
  METHODS
  Cigna-HealthSpring's medical claims data was used to identify patients with HTN and DM diagnoses by using ICD-9-CM codes 401 and 250, and at least 2 fills for ACEIs or ARBs between January 2013 and October 2013. Patients who failed to refill their medication for more than 1 day and had a proportion of days covered (PDC) < 0.8 were considered nonadherent and were contacted by a pharmacist by phone to identify adherence barriers. Two outcome variables were evaluated: The first was adherence to ACEIs/ARBs, defined as PDC during the 6 months following the phone call intervention. The second outcome variable was a categorical outcome of discontinuation versus continuation. Discontinuation was defined as not using ACEIs/ARBs during the 6-month post-intervention period. Patients who disenrolled from the plan in 2014 or were switched to another medication commonly used for treating DM and HTN were excluded from further analysis. Descriptive statistics were conducted to assess the frequency distribution of sample demographic characteristics at baseline. Multiple linear regression was conducted to assess the intervention effect on adherence during the 6 months post-intervention using the first outcome of post-intervention PDC, adjusting for baseline PDC and other covariates. Logistic regression was performed to assess the association between medication discontinuation and other baseline characteristics using the second outcome of discontinuation. Other control variables in the models included demographics (age, sex, language), physician specialty (primary care vs. specialist), health plan (low-income subsidy vs. other), Centers for Medicare & Medicaid risk score, Charlson Comorbidity Index, and number of distinct medications.
  
  
  RESULTS
  In total, 186 hypertensive diabetic patients, nonadherent to ACEIs/ARBs (PDC < 0.8), were included in the study. Of the 186 patients, 87 received the pharmacist phone call intervention. Among these patients, forgetfulness (25.29%) and doctor issues, such as having difficulty scheduling appointments (16.79%), were the most commonly reported barriers. After excluding those who switched from ACEIs/ARBs to another medication, 157 patients were included in the logistic regression model. Of those, 131 had continued using ACEIs/ARBs and were included in the linear regression model. The mean (±SD) post-intervention PDC for the intervention group was 0.58 (±0.26) and for the control group 0.29 (±0.17). Intervention was a significant predictor of better adherence in the linear regression model after adjusting all the other baseline covariates (β = 0.3182, 95% CI = 0.19-0.38, P < 0.001). Other covariates were not significantly associated with better adherence. In the logistic regression model (discontinuation: 26 [yes]/131 [no]) for predicting medication discontinuation, patients who received intervention were more likely to continue using ACEIs/ARBs (OR = 3.56, 95% CI = 1.06-11.86), and those with a higher comorbidity index were less likely to continue using them (OR = 0.72, 95% CI = 0.53-0.99).
  
  
  CONCLUSIONS
  The brief pharmacist telephone intervention resulted in significantly better PDCs during the 6 months following the intervention as well as lower discontinuation rates among a group of nonadherent patients with comorbid HTN and DM. The overall PDC rates in both the intervention and control groups were still lower than the recommended 80%. Improving adherence to clinically meaningful values may require more than a brief pharmacist phone call. Incorporating motivational interviewing techniques with follow-up calls to address adherence barriers may be more influential in forming sustainable behavioral change and enhancing medication adherence.
authors.affiliation: 1 Assistant Professor, Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Abughosh
authors.affiliation: 2 Graduate Student, Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Xin
authors.initials: X
authors.lastname: Wang
authors.affiliation: 3 Clinical Operations Director, Cigna-HealthSpring, Houston, Texas.
authors.forename: Omar
authors.initials: O
authors.lastname: Serna
authors.affiliation: 4 Pharmacy Resident, Cigna-HealthSpring, Houston, Texas.
authors.forename: Chris
authors.initials: C
authors.lastname: Henges
authors.affiliation: 5 Clinical Assistant Professor, Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Santhi
authors.initials: S
authors.lastname: Masilamani
authors.affiliation: 6 Professor, Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Ekere James
authors.initials: EJ
authors.lastname: Essien
authors.affiliation: 5 Clinical Assistant Professor, Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Nancy
authors.initials: N
authors.lastname: Chung
authors.affiliation: 1 Assistant Professor, Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas.
authors.forename: Marc
authors.initials: M
authors.lastname: Fleming
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000188:drug therapy*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D016015:Logistic Models; D008297:Male; D006278:Medicare; D055118:Medication Adherence; D010593:Pharmaceutical Services; D010595:Pharmacists; D013689:Telephone; D014481:United States
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents