Impact of the SIMPL-SYNC Refill Synchronization Program on medication adherence: A pragmatic randomized controlled trial.

OBJECTIVE: To determine the impact of the SIMPL-SYNC refill synchronization (SSRS) service compared with that of usual care (UC) on medication adherence when applied as an opt-out strategy among patients receiving chronic medications. DESIGN: This was a pragmatic randomized controlled trial. SETTING AND PARTICIPANTS: The study was conducted in 2 community pharmacies located in Saskatchewan, Canada. Eligible patients were chronic medication users visiting the study pharmacies. OUTCOME MEASURES: The primary outcome was the percentage of individuals achieving optimal adherence to all eligible study medications. Eligible study medications included 22 commonly used medication classes used to treat diverse conditions. Adherence was assessed for each medication class after 300 days using the proportion of days covered (PDC). Optimal adherence was defined as PDC ≥ 80%. RESULTS: A total of 488 patients were screened for eligibility, and 190 patients were included in the intention-to-treat analysis (95 in SSRS, 95 in UC). The mean age of participants was 59 years, and 34% (65/190) were older than 65 years. A total of 574 individual adherence observations representing the 22 eligible study medication classes were generated from the 190 study participants. The percentage of individuals achieving optimal adherence to all their eligible study medications was 50.5% (48/95) in the SSRS group versus 44.2% (42/95) in the UC group (P = 0.383). Similarly, no statistically significant difference was observed in a per-protocol analysis assessing people who participated fully in the service; the percentage of individuals achieving optimal adherence to all their eligible study medications was 55.1% (38/69) in SSRS versus 40.7% (33/81) in UC (P = 0.080). Patient refusal of the refill synchronization services was common among randomized patients. CONCLUSION: SSRS service failed to detect a robust improvement in medication adherence when delivered using an opt-out strategy. However, small improvements in adherence or benefits to specific subgroups of patients could not be ruled out.

Potential cost-savings from the use of the biosimilars filgrastim, infliximab and insulin glargine in Canada: a retrospective analysis.

BACKGROUND: In 2014 and 2015, biosimilars for the drugs filgrastim, infliximab, and insulin glargine were approved for use in Canada. The introduction of biosimilars in Canada could provide significant cost savings for the Canadian healthcare system over originator biologic drugs, however it is known that the use of biosimilars varies widely across the world. The aim of this study was to estimate the use of biosimilars in Canada and potential cost-savings from their use. METHODS: We performed a retrospective analysis of Canadian drug purchases for filgrastim, infliximab, and insulin glargine from July 2016 to June 2018. This was a cross-sectional study and the time horizon was limited to the study period. As a result, no discounting of effects over time was included. Canadian drugstore and hospital purchases data, obtained from IQVIA™, were used to estimate the costs per unit and unit volume for biosimilars and originator biologic drugs within each province. Potential cost-savings were calculated as a product of the units of reference originator product purchased and the cost difference between the originator biologic and its corresponding biosimilar. RESULTS: The purchase of biosimilars varied by each province in Canada, ranging from a low of 0.1% to a high of 81.6% of purchases. In total, $1,048,663,876 Canadian dollars in savings could have been realized with 100% use of biosimilars over the originator products during this 2 year time period. The potential savings are highest in the province of Ontario ($349 million); however, even in smaller markets (PEI and Newfoundland), $28 million could have potentially been saved. Infliximab accounted for the vast majority of the potential cost-savings, whereas the purchases of the biosimilar filgrastim outpaced that of the originator drug in some provinces. In sensitivity analyses assuming only 80% of originator units would be eligible for use as a biosimilar, $838 million dollars in cost savings over this two-year time period would still have been realized. CONCLUSIONS: The overall use of biosimilar drugs in Canada is low. Policy makers, healthcare providers, and patients need to be informed of potential savings by increased use of biosimilars, particularly in an increasingly costly healthcare system.

Correction to: Potential cost-savings from the use of the biosimilars filgrastim, infliximab and insulin glargine in Canada: a retrospective analysis.

In the original publication of this article [1], there is a mistake in the Fig. 2a, 2b, and 2c.

Community pharmacists' experiences with the Saskatchewan Medication Assessment Program.

BACKGROUND: The Saskatchewan Medication Assessment Program (SMAP) is a publicly funded community pharmacy-based medication assessment service with limited previous evaluation. The purpose of this study was to explore community pharmacists' experiences with the SMAP. METHODS: Online, self-administered questionnaire that consisted of a combination of 53 Likert scale and free-text questions. All licensed pharmacists who were practising in a community pharmacy setting in Saskatchewan were eligible to participate. RESULTS: Response rate was 20.3% (n = 228/1124). Most respondents agreed that the SMAP is achieving all of its intended purposes. For example, 89.7% agreed that the SMAP improved medication safety for patients who receive the service. Most pharmacists enjoyed performing the assessments (84.6%) and were confident in their ability to identify drug-related problems (88.3%). Pharmacists reported lack of time, patients having difficulty coming to the pharmacy and restrictive eligibility criteria as the top barriers to the SMAP. Good teamwork, employer support and personal professional commitment were the top recognized facilitators. Respondents made several suggestions to improve the SMAP in the free-text areas of the questionnaire. CONCLUSIONS: Community pharmacists in Saskatchewan were positive and confident about performing medication assessments, and most agreed that the SMAP is achieving all of the intended purposes. Respondents also identified several barriers to providing SMAP services, which have resulted in specific recommendations that should be addressed to improve the program.

Influence of Flaxseed Lignan Supplementation to Older Adults on Biochemical and Functional Outcome Measures of Inflammation.

Evidence from the literature suggests that dietary flaxseed lignans have the ability to modulate inflammation, which is recognized as the underlying basis of multiple chronic human diseases in older adults. Our objective was to determine the effects of oral lignan supplementation on biochemical and functional indicators of inflammation as well as safety and tolerability in older healthy adults. We designed a randomized, double-blind, placebo-controlled clinical trial in older healthy adults (60-80 years) to assess flaxseed lignan-enriched complex (∼38% secoisolariciresinol diglucoside [SDG]; 600 mg SDG dose) oral supplementation effects on biochemical and functional indicators of inflammation and safety and tolerability in older healthy adults after 6 months of once-daily oral administration. The clinical trial confirmed that plasma concentration of total flaxseed lignans (free and conjugated forms) secoisolariciresinol (SECO), enterodiol (ED), and enterolactone (ENL) were significantly associated with daily oral supplementation of flaxseed lignan-enriched complex (p < 0.05). A significant decrease in systolic blood pressure (SBP; from a mean of 155 ± 13 mm Hg at baseline to 140 ± 11 mm Hg at 24 weeks) was observed in lignan-supplemented participants stratified into an SBP ≥140 mm Hg subcategory (p = 0.04). No differences were found between treatment or placebo groups in terms of cognition, pain, activity, physical measurements (calf, waist, and upper arm circumstances), and grip strength. With respect to blood inflammatory markers, lipid profiles, and biochemical parameters, no significant differences were found between treatment and placebo groups at the end of the 6-month supplementation. No adverse effects were reported during supplementation. These data further support the safety and tolerability of long-term flaxseed lignan-enriched complex supplementation in older adults and identify an ability to favorably modulate SBP, an important risk factor in cardiovascular disease.

The association between self-monitoring of blood glucose, hemoglobin A1C and testing patterns in community pharmacies: Results of a pilot study.

OBJECTIVES: To determine if pharmacists providing advice on self-monitoring of blood glucose (SMBG) to new meter users, based on the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs), resulted in improvements in A1C. SMBG testing patterns and pharmacist interactions were also observed. METHODS: A cluster randomized, pilot study was performed, with pharmacies randomized to an intervention or control group. The intervention group provided SMBG education according to the CDA CPGs at baseline, 2 weeks, 1 month and 3 months; the control group provided usual care. The primary endpoint was the mean change in A1C measured at 6 months. Secondary endpoints included a description of SMBG patterns and lifestyle changes and were determined via a self-administered questionnaire. RESULTS: Thirty-six participants (26 intervention, 10 control) were recruited from 9 pharmacies across Saskatchewan, Canada. Mean A1C decreased by -1.69 and -0.70 in the intervention and control groups, respectively (p = 0.376). A total of 12 of 26 (46.2%) participants in the intervention group indicated they performed SMBG ≥7 times per week; 75% (9/12) of these were controlled by lifestyle or metformin alone. When applicable, most participants in the intervention group indicated they perform SMBG with exercise (62.5%), during illness (62.5%) and with hypoglycemic symptoms (81.3%) compared with 33.3%, 42.9% and 42.9% in the control group, respectively. Most participants in the intervention group (20/26; 76.9%) reported making lifestyle changes as a result of speaking with the pharmacist, with all indicating that they maintained these changes at 6 months. CONCLUSIONS: The results of this pilot study indicate that a larger study examining pharmacist interventions related to SMBG is feasible. Future studies are required to determine patient motivations and further evaluate the role of pharmacists in ensuring best practices to positively influence guideline-based blood glucose monitoring.

A questionnaire examining attitudes of collegiate athletes toward doping and pharmacists as information providers.

BACKGROUND: Doping in sport has become an increasingly prominent topic. The decision to take part in doping practices is multifactorial and often based on many different information sources of varying reliability. This study sought to determine the attitudes of athletes at a Canadian Interuniversity Sport (CIS) university toward doping and to discover if pharmacists are perceived to be a valid information source on medication usage for these athletes. METHODS: CIS athletes competing in at least 1 of 8 sports were asked to complete a questionnaire. Participants were asked various questions regarding their perceptions of doping, medication use, information available to them regarding doping and the role of pharmacists in providing advice on medication usage. RESULTS: In total, 92.7% (307/331) of questionnaires were at least partially completed. Generally, these athletes did not feel pressured to dope or that it was prevalent or necessary. The fear of doping violations largely did not alter the use of medications and supplements. The online doping education program administered by the Canadian Centre for Ethics in Sport was the most used information source (74.5%); pharmacists were used 37.7% of the time. Pharmacists were perceived to be a good source of information about banned substances by 75.6% (223/295) of participants, although only 35% (104/297) consulted a pharmacist each time they purchased a nonprescription medication. CONCLUSIONS: It appears that doping is neither prevalent nor worth the risk for these CIS athletes. There also appears to be an opportunity for pharmacists to play a more prominent role in providing advice on medication use to high-performance athletes.

Collaborative Cardiovascular Risk Reduction in Primary Care II (CCARP II): Implementation of a systematic case-finding process for patients with uncontrolled risk factors.

BACKGROUND: Previous pharmacist interventions to reduce cardiovascular (CV) risk have been limited by low patient enrolment. The primary aim of this study was to implement a collaborative pharmacist intervention that used a systematic case-finding procedure to identify and manage patients with uncontrolled CV risk factors. METHODS: This was an uncontrolled, program implementation study. We implemented a collaborative pharmacist intervention in a primary care clinic. All adults presenting for an appointment with a participating physician were systematically screened and assessed for CV risk factor control by the pharmacist. Recommendations for risk factor management were communicated on a standardized form, and the level of pharmacist follow-up was determined on a case-by-case basis. We recorded the proportion of adults exhibiting a moderate to high Framingham risk score and at least 1 uncontrolled risk factor. In addition, we assessed before-after changes in CV risk factors. RESULTS: Of the 566 patients who were screened prior to visiting a participating physician, 186 (32.9%) exhibited moderate or high CV risk along with at least 1 uncontrolled risk factor. Physicians requested pharmacist follow-up for 60.8% (113/186) of these patients. Of the patients receiving the pharmacist intervention, 65.5% (74/113) were at least 50% closer to 1 or more of their risk factor targets by the end of the study period. Significant risk factor improvements from baseline were also observed. DISCUSSION: Through implementation of a systematic case-finding approach that was carried out by the pharmacist on behalf of the clinic team, a large number of patients with uncontrolled risk factors were identified, assessed and managed with a collaborative intervention. CONCLUSION: Systematic case finding appears to be an important part of a successful intervention to identify and manage individuals exhibiting uncontrolled CV risk factors in a primary care setting.

The development of a Cannabis Knowledge Assessment Tool (CKAT).

BACKGROUND: Misconceptions about the health risks of cannabis remain prevalent, indicating the need to improve public health messaging and determine the effectiveness of educational programming. Our objective was to develop a standardized questionnaire to measure knowledge about cannabis in the context of cannabis legalization. METHODS: A Cannabis Knowledge Assessment Tool (CKAT) was created using the Delphi method. A purposive sample of healthcare professionals, policymakers, academics, patients, and students served as the content and development experts. Principal component analysis from the codes identified from open-ended feedback guided the item development. Upon completion, the CKAT was administered as a pre- and post-test in four schools (7th and 9th Grade) in Canada. The data were analysed to determine whether knowledge scores changed after participating in a cannabis education program. RESULTS: Twenty-four experts initially participated in the Delphi process and 18 (75% retention) continued throughout. Principal component analysis identified 3 domains: 1) effects of cannabis on the individual, 2) general information about cannabis, and 3) cannabis harm reduction. The final questionnaire consisted of 16 multiple-true-false questions (64 items) and received a Flesch-Kincaid Grade Level of 6.3, and a SMOG index score of 7.6. The CKAT was completed by 132 students; seventy-three 7th grade and fifty-nine 9th grade students. The baseline mean CKAT score was 46.2 (SD:5.5), which increased to 50.7 (SD:4.6) after the cannabis educational program (p<0.05). CONCLUSIONS: A novel tool to measure knowledge of cannabis was developed and piloted in 7th grade and 9th grade students. Future studies are required to test usability and validity of the CKAT in other contexts.

Proposing a redefinition of pharmaceutical care.

In many clinical practice settings, individual pharmaceutical care practitioners have thousands of patients who may receive their service. However, the pharmaceutical care approach provides virtually no guidance regarding how patients should be identified or prioritized by practicing pharmacists. We believe that pharmacists need to be "officially" accountable to specific patient groups at high risk for drug- or disease-induced morbidity within their practice. Consequently, the current definition of pharmaceutical care and its associated care processes need to be modified to ensure the activities of pharmacists are being focused on high-priority patients on a consistent basis.

Prevalence of metabolic syndrome among college football linemen.

OBJECTIVE: To determine the prevalence of metabolic syndrome among Canadian amateur football players. METHODS: University football players from Saskatchewan were invited to participate in this study. Each subject underwent screening for blood pressure using a BpTRU monitor, and serum cholesterol and fasting blood glucose using a Cholestech LDX analyzer. Waist circumference was recorded and body composition was measured by dual-energy x-ray absorptiometry. RESULTS were compared between linemen and non-linemen using independent sample t-tests for continuous data and chi-square for dichotomous variables. RESULTS: Out of 39 players who consented to participate, 14% of linemen (3/21) and no non-linemen satisfied metabolic syndrome criteria. Compared to non-linemen, linemen had a higher waist circumference (108.0 vs. 82.9 cm; p<0.001), higher total body fat composition (26.4% vs. 11.2%; p<0.001), lower mean high-density lipoprotein cholesterol (0.93, vs. 1.12 mmol/L; p=0.021) and higher fasting blood glucose (5.22 vs. 4.77 mmol/L; p<0.001). CONCLUSION: Despite their young age and participation in an elite-level athletic program, many collegiate-level football linemen had features of metabolic syndrome. Although our study focused on a single team, we suspect these trends may be consistent across the country.

Current cancer therapies and their influence on glucose control.

This review focuses on the development of hyperglycemia arising from widely used cancer therapies spanning four drug classes. These groups of medications were selected due to their significant association with new onset hyperglycemia, or of potentially severe clinical consequences when present. These classes include glucocorticoids that are frequently used in addition to chemotherapy treatments, and the antimetabolite class of 5-fluorouracil-related drugs. Both of these classes have been in use in cancer therapy since the 1950s. Also considered are the phosphatidyl inositol-3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR)-inhibitors that provide cancer response advantages by disrupting cell growth, proliferation and survival signaling pathways, and have been in clinical use as early as 2007. The final class to be reviewed are the monoclonal antibodies selected to function as immune checkpoint inhibitors (ICIs). These were first used in 2011 for advanced melanoma and are rapidly becoming widely utilized in many solid tumors. For each drug class, the literature has been reviewed to answer relevant questions about these medications related specifically to the characteristics of the hyperglycemia that develops with use. The incidence of new glucose elevations in euglycemic individuals, as well as glycemic changes in those with established diabetes has been considered, as has the expected onset of hyperglycemia from their first use. This comparison emphasizes that some classes exhibit very immediate impacts on glucose levels, whereas other classes can have lengthy delays of up to 1 year. A comparison of the spectrum of severity of hyperglycemic consequences stresses that the appearance of diabetic ketoacidosis is rare for all classes except for the ICIs. There are distinct differences in the reversibility of glucose elevations after treatment is stopped, as the mTOR inhibitors and ICI classes have persistent hyperglycemia long term. These four highlighted drug categories differ in their underlying mechanisms driving hyperglycemia, with clinical presentations ranging from potent yet transient insulin resistant states [type 2 diabetes mellitus (T2DM) -like] to rare permanent insulin-deficient causes of hyperglycemia. Knowledge of the relative incidence of new onset hyperglycemia and the underlying causes are critical to appreciate how and when to best screen and treat patients taking any of these cancer drug therapies.

An Advanced Pharmacy Practice Experience for Community Pharmacies Based on a Clinical Intervention Targeting Patients With Inflammatory Bowel Disease.

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

Development of the REACH (Real Education About Cannabis and Health) Program for Canadian Youth.

BACKGROUND: Because cannabis use in children can have negative consequences, the recent legalization of recreational cannabis for adults in Canada creates an urgent need for youth education. METHOD: A multidisciplinary clinical rotation was developed wherein nursing and pharmacy students collaborated with youth (grades 7 through 10) to construct an educational program about cannabis. Four schools participated, representing a variety of socioeconomic demographics. Feedback was solicited from students and stakeholders. The purpose of this project was to create REACH (Real Education About Cannabis and Health), a toolkit and curriculum resource that includes lesson plans for teachers covering the science of cannabis, social science implications, peer pressure, decision making and harm reduction, videos featuring youth testimonials, and supplemental resources. RESULTS: Preliminary feedback suggests the materials are engaging and informative. CONCLUSION: A collaboration of health science students with youth in schools resulted in an authentic and relatable educational program about cannabis. Future studies will evaluate REACH's effectiveness in seventh- and ninth-grade students. [J Nurs Educ. 2020;59(8):465-469.].

Prevalence of Type 1 and Type 2 Diabetes-Related Complications and Their Association With Determinants Identified in Canada's Survey on Living With Chronic Diseases-Diabetes Component.

OBJECTIVES: In this study, we estimated the prevalence of diabetes-related complications and the factors associated with them in Canadian patients with diabetes. METHODS: Data from the 2011 Survey on Living with Chronic Diseases in Canada---Diabetes Component (SLCDC-DM-2011) were used to calculate the weighted prevalence of 16 diabetes-related complications. A multivariable, sex-stratified logistic regression model was used to examine the association between each diabetes-related complication and select determinants. RESULTS: Among Canadian patients who self-reported having diabetes, 80.26% reported having at least 1 type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%) and poor circulation (21.68%). Male patients were more associated to have at least 1 complication if they had an inappropriate body mass index (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.39 to 6.23) and had a high level of glycated hemoglobin (OR, 2.32; 95% CI, 1.05 to 5.13), were older (OR, 6.92; 95% CI, 1.82 to 24.74) and had diabetes for a longer period of time (OR, 3.42; 95% CI, 1.71 to 6.85). Among the female patients, a longer duration diabetes was found to have a significant association with complications (OR, 2.00; 95% CI, 1.05 to 3.81). CONCLUSIONS: Our findings suggest that socioeconomic factors, including marital status, income and education, have a significant association with most types of complications. Our findings also confirm that low levels of physical activity and high levels of glycated hemoglobin were major determinants in many diabetes-related complications.

Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes.

OBJECTIVES: The aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization. METHODS: Administrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported. RESULTS: A total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94). CONCLUSION: Our findings add to the body of evidence against a protective effect of blood glucose test strip use for serious hypoglycemia.

Retrospective observational assessment of statin adherence among subjects patronizing different types of community pharmacies in Canada.

BACKGROUND: Community pharmacies vary widely in terms of ownership structures, location, and dispensing policies. It is unknown if an association exists between the type of community pharmacy and the degree of medication adherence exhibited by patrons-patients. OBJECTIVE: To describe adherence to statin therapy among subjects patronizing different types of community pharmacy categories (department- mass merchandise, chain-franchise, and independent-banner) in Saskatchewan, Canada, between 2000 and 2005. METHODS: Study data were obtained from the Saskatchewan Drug Plan and Extended Benefits database, which is maintained by the government of Saskatchewan, Canada. The study included all subjects who (a) filled a statin prescription within selected community pharmacies between January 1, 2000, and December 31, 2005; (b) had no record of statin prescriptions during the year prior to the first statin prescription, according to the records of the Saskatchewan Drug Plan and Extended Benefits; and (c) demonstrated active utilization in the drug plan database for at least 1 year after the first statin prescription. The proxy criterion for activity was any dispensing record for statin or nonstatin medications at least 1 year following the index claim. Statin adherence level was estimated as tablets per day, defined as the total number of tablets dispensed divided by the total number of days of observation. Each subject's observation period began on the index date and ended on the earlier of (a) 30 days after the last recorded fill for any type of prescription medication (statin or nonstatin), or (b) December 31, 2005. The primary end point was the proportion of subjects within each pharmacy category who maintained an adherence level of 80% or greater during their individual observation period. Additional adherence calculations were performed for each of 3 time periods, beginning on the index date and ending on days 365, 729, and 1094 (i.e., 1, 2, and 3 years). Patients were included in the analysis for each time period if they met a proxy criterion for availability for observation, defined as the dispensing of any drug at least 1 day after the end date of each period. Pearson chi square tests were used to assess the significance of differences in baseline characteristics and adherence proportions, comparing pharmacy categories. Logistic regression analysis estimated the odds of an adherence level of at least 80% during the individual observation period, adjusting for pharmacy category, sex, age 65 years or older, known low-income drug coverage, number of distinct drug classes filled concurrently during the first year of observation, loyalty to index pharmacy, and length of observation. Using similar methods, we also estimated "pharmacy loyalty" by calculating the proportion of subjects who refilled 75% or more of their statin prescriptions at the pharmacy that dispensed their first statin prescription. RESULTS: From an initial sample of 12,818 subjects who had at least 1 pharmacy claim for a statin in the period from January 1, 2000, through December 31, 2005, 8699 subjects met the inclusion criteria. Subjects were observed for a mean (SD, range) of 3.7 (1.7, 1.0-7.0) years after the index statin prescription. During the first year following the index claim, statin adherence rates were at least 80% for 1799 of 3761 (47.8%) patrons of department-mass merchandise, 1778 of 3235 (55.0%) patrons of chain-franchise, and 921 of 1703 (54.1%) patrons of independent-banner stores (P < 0.001). Measured from the index date through day 1094, 869 of 2292 (37.9%), 874 of 1887 (46.3%), and 457 of 975 (46.9%) subjects in the department-mass merchandise, chain-franchise, and independent banner categories, respectively, had a statin adherence level of at least 80% (P < 0.001). In logistic regression analysis, pharmacy category type was significantly associated with statin adherence; subjects in the chain franchise and independent-banner categories were more likely to be adherent to their statin medications during their observation periods than were those in the department-mass merchandise category (adjusted odds ratio [OR] = 1.36, 95% CI = 1.23-1.50, P < 0.001 and OR = 1.39, 95% CI = 1.24-1.57, P < 0.001, respectively). From the index date through day 1094, 1752 of 2292 (76.4%), 1475 of 1887 (78.2%), and 795 of 975 (81.5%) subjects remained pharmacy-loyal in the department-mass merchandise, chain franchise, and independent-banner categories, respectively (P = 0.006). Controlling for several potential confounders using logistic regression, independent-banner pharmacy patrons were more likely to remain pharmacy- loyal during their observation periods than were those patronizing department-mass merchandise (adjusted OR = 1.34, 95% CI = 1.16-1.54, P < 0.001) or chain-franchise stores (adjusted OR = 1.22, 95% CI = 1.06-1.42, P = 0.009). CONCLUSION: One year after their first statin fill, subjects demonstrated low rates of adherence, ranging from 48% to 55%, regardless of the type of pharmacy they patronized. Although the differences by type of pharmacy reached statistical significance, their clinical importance is not evident, reinforcing the fact that the problem of nonadherence appears to exist among all types of community pharmacies, regardless of their categorization.