By Annette M. Boyle
PHILADELPHIA—As every pharmacist and physician knows, medications only work if patients take them as prescribed—and increasing consistent adherence remains one of the biggest challenges in medicine.
Refill synchronization, a program that refills a patient’s maintenance medications at the same time, might offer an inexpensive and effective way to do that, according to new research.1
More than 20 pharmacy chains and 2,000 independent pharmacies now offer refill synchronization as a convenience for customers. A study published recently in Health Affairs found that the programs not only boost adherence, they also show the greatest benefit among patients who have historically been the least likely to take their medications consistently.
The increase in adherence could be a real boon within the VA, as nearly two-thirds of veterans suffer from at least one chronic illnesses and one-third have been diagnosed with three or more.2 For those patients, remembering what needs to be renewed when and then getting out to pick up the prescriptions can create a significant burden.
“Synchronized refills have the advantage of making it easier for patients to keep track of when prescriptions are due and obtaining timely refills and renewals, as typically when these are all on different schedules it necessitates keeping track of multiple renewal dates,” said Kevin Volpp, MD, PhD, of the Philadelphia VAMC, director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute and professor of medicine and healthcare management at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania.
Researchers, including Volpp, evaluated a pilot program offered to Medicare Advantage patients by Humana that refilled and mailed out their antihypertensive, lipid-lowering or antidiabetic medications simultaneously. All participants had between two and six maintenance medication prescriptions. The study followed 1,386 patients for 12 months, including 691 who accepted an invitation to participate in the synchronized-refill program and 695 who were eligible for the intervention but not asked to participate. During the study, 15% of those in the refill program dropped out for various reasons.
The researchers considered patients adherent if their proportion of days covered (PDC) with a day’s supply of a medication from at least one prescription in a drug class met or exceeded 80%.
On average, the absolute increase in the proportion of patients considered adherent rose 3 to 10 percentage points for those receiving synchronized refills compared to 1 to 5 percentage point increases for those who did not participate in the program.
Patients whose proportion of days covered at the start of the study was below 60% demonstrated the greatest increase over the 12-month period. In this group, adherence rose 23 percentage points for antihypertensives, 26 points for lipid-lowering drugs and 25 points for antidiabetic agents.
The average increase in adherence might not seem significant, but it is compares favorably to other initiatives—and can make a difference in outcomes. The study’s results are “similar in magnitude to value-based insurance design initiatives that have lowered copayments to patients in efforts to increase adherence,” Volpp told U.S. Medicine. Studies of programs that reduce copayments have found that average adherence improves about three percent in one year, according to the study.
Relatively small improvements in adherence can have a significant effect on outcomes. “Two seminal studies have indeed found that modest differences in adherence levels for cardiovascular and diabetes medications are associated with changes in physiological outcomes and cardiovascular events,” the authors noted. Further, “boosting adherence to cardiovascular medications to or above an 80% cutoff (as used in our study) is indeed associated with lower risk of adverse cardiovascular events.”
While Volpp said that he was not aware of any VA plans to implement synchronized refills, it could be particularly beneficial to veterans, as the majority use mail-order pharmacies like the patients in the study. The VA’s Consolidated Mail Outpatient Pharmacies handle about 80% of the VA’s prescriptions, sending out more than 120 million prescriptions every year. In July 2014, 10,204,401 prescriptions were processed by centralized mail-order pharmacies, and an additional 631,805 prescriptions were mailed from medical centers, Pharmacy Benefits Management previously told U.S. Medicine.
Having multiple prescriptions refilled simultaneously would simplify the process for veterans and make monitoring delivery of mail-ordered prescriptions easier as well. Veterans could go on HealtheVet and check only one tracking number to see where all their maintenance medications are, Volpp noted.
“For patients getting refills in-person, it also saves the need for multiple trips to the pharmacy,” he said, which can be a significant challenge for veterans with limited mobility, transportation issues or in rural locations.
The program could have downsides, too. For veterans who have copays, for instance, synchronization would increase the amount they have to pay at any one point rather than spreading it out over a period of time. “For low-income populations, that is an important consideration, as they may not have sufficient cash on hand to pay the copayments on all their medications at once,” Volpp said.
Synchronization has advantages and disadvantages on the pharmacy side, as well. “To the extent prescriptions change over time, synchronization would require ongoing attention to keeping prescriptions in sync,” Volpp said. “On the other hand, it has the advantage that all of a patient’s prescriptions can be processed at once, as opposed to multiple times, which may be a particular advantage in the context of mail-order pharmacies.”
1 Doshi JA, Lim R, Li P, Young PP, Lawnicki VF, State JJ, Troxel AB, Volpp KG. A Synchronized Prescription Refill Program Improved Medication Adherence. Health Aff (Millwood). 2016 Aug 1;35(8):1504-12.
2 Yoon J, Scott JY, Phibbs CS, Wagner TH. Recent trends in Veterans Affairs chronic condition spending. Popul Health Manag. 2011 Dec;14(6):293-8.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.