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Impact of an antidepressant adherence
program in a managed care organization
Kara Zivin Bambauer, PhD
Stephen Soumerai, ScD
Alyce Adams, PhDFang Zhang, PhD
Rick Weisblatt, PhDNeil Minkoff, MD
Andrea Grande, RPhDennis Ross-Degnan,
ScD
Harvard Pilgrim Health Care and Harvard Medical School
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Background The burden of depression is substantial
Effective medications are available to treat depression
Non-adherence to antidepressants remains a substantial problem
Harvard Pilgrim Health Care (HPHC) sought to improve quality of care for depression using available electronic data
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Objectives
To evaluate the effectiveness of providing faxed feedback to physicians regarding patient refill behavior
Does the proportion of patients who are potentially non-adherent to treatment decrease after the policy?
Does the proportion of days within a treatment episode without antidepressant coverage decrease after the policy?
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Content of Fax Introduction: This is a clinical reminder to assist
physicians who are treating patients for Major Depressive Disorder (MDD)
Explanation: There are 3 quality of care measures for depression treatment
Summary: information on antidepressant compliance Symptoms usually remit in 4-6 weeks Therapy should be continued for 6 months Only 40% of patients of patients adhere to
antidepressant treatment
Closing: Your patient (insert name) has gone more than 10 days without antidepressant treatment (medication name, dose, quantity)
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Antidepressant Compliance Program (ACP) Definitions
Adherent: antidepressant prescription refilled within 10 days of an expected refill If not, a fax is sent to the prescribing physician
Potentially non-adherent: antidepressant prescription refilled more than 10 days and less than 30 days after an expected refill
Failure: antidepressant prescription not refilled within 30 days of an expected refill
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Assumptions Underlying ACP
The prescribing physician receives the fax
The physician makes contact with the patient
A physician-patient conversation occurs that effectively deals with the reasons for patient non-adherence
The patient subsequently refills the antidepressant prescription in a timely manner
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Inclusion Criteria All HPHC members were eligible
All types of providers were included
Each patient needed to be enrolled for 6 months before and 6 months after first antidepressant use
Patients were included who used a select subset of antidepressants usually indicated for treatment of depression
New users of antidepressants (no use in previous 100 days)
First episode of antidepressant treatment for each person
Age ≥ 18
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Timeline
5/ 15/ 2003 - 5/ 14/ 2004First year of ACP
2/ 15/ 2003 - 5/ 14/ 2003Phase-in period (data excluded from analysis)
5/ 15/ 2002 - 2/ 14/ 2003Pre-ACP period
5/ 15/ 2003ACP begins
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Methods
Interrupted time-series (ITS) analysis using SAS PROC AUTOREG
Used to evaluate rates of change in adherence due to the ACP
Look at slope and level changes
ITS is one of the strongest quasi-experimental designs for studying policy changes
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Characteristics of Study Participants (N=13,128)
Mean age (sd): 42 (11) Gender: 69% female Policy Variables
Adherent: 18% Potentially non-adherent: 29% Failure: 53%
No significant differences in pre-policy and post-policy patients
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0%
10%
20%
30%
40%
50%
60%
70%
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100%
May-02Aug-02 Nov-02 Feb-03 May-03Aug-03 Nov-03 Feb-04 May-04
% w/ gaps & fail model expected
Perc
en
t A
dh
ere
nce
Fail
ure
sPercent of Non-Adherent Patients Who
Proceed to Adherence Failure
Pre-ACP period
First year of ACP
Phase-in period
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0%
10%
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40%
50%
60%
70%
80%
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100%
May-02Aug-02 Nov-02 Feb-03 May-03Aug-03 Nov-03 Feb-04 May-04
% coverage model expected
Phase-in periodP
erc
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t T
reatm
en
t D
ays
U
ncove
red
Mean Percent of Treatment Days Not Covered
Pre-ACP period
First year of ACP
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Limitations and Implications
Electronic reminder systems, while popular, may not improve patient adherence
Success of such interventions requires a complex chain of events to occur
We cannot determine from electronic data whether communication between physicians and patients addresses reasons for patient non-adherence
Stand alone interventions targeting adherence are not successful
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Conclusions The ACP was not successful at increasing
antidepressant adherence rates in HPHC members
Additional research should re-examine assumptions underlying the ACP to identify ways to improve future antidepressant adherence interventions
Effectiveness of electronic interventions should be carefully evaluated before widespread implementation