Adherence and Viral Suppression Among Participants of the Patient-centered Human Immunodeficiency Virus (HIV) Care Model Project: A Collaboration Between Community-based Pharmacists and HIV Clinical Providers.

BACKGROUND: Human immunodeficiency virus (HIV) viral suppression (VS) decreases morbidity, mortality, and transmission risk. METHODS: The Patient-centered HIV Care Model integrated community-based pharmacists with HIV medical providers and required them to share patient clinical information, identify therapy-related problems, and develop therapy-related action plans.Proportions adherent to antiretroviral therapy (proportion of days covered [PDC] ≥90%) and virally suppressed (HIV RNA <200 copies/mL), before and after model implementation, were compared. Factors associated with postimplementation VS were determined using multivariable logistic regression; participant demographics, baseline viral load, and PDC were explanatory variables. PDC was modified to account for time to last viral load in the year postimplementation, and stratified as <50%, 50% to <80%, 80% to <90%, and ≥90%. RESULTS: The 765 enrolled participants were 43% non-Hispanic black, 73% male, with a median age of 48 years; 421 and 649 were included in the adherence and VS analyses, respectively. Overall, proportions adherent to therapy remained unchanged. However, VS improved a relative 15% (75% to 86%, P < .001). Higher PDC (adjusted odds ratio [AOR], 1.74 per 1-level increase in PDC category [95% confidence interval {CI}, 1.30-2.34]) and baseline VS (AOR, 7.69 [95% CI, 3.96-15.7]) were associated with postimplementation VS. Although non-Hispanic black persons (AOR, 0.29 [95% CI, .12-.62]) had lower odds of suppression, VS improved a relative 23% (63% to 78%, P < .001). CONCLUSIONS: Integrated care models between community-based pharmacists and primary medical providers may identify and address HIV therapy-related problems and improve VS among persons with HIV.

Improvements in Retention in Care and HIV Viral Suppression Among Persons with HIV and Comorbid Mental Health Conditions: Patient-Centered HIV Care Model.

The Patient-centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers and required sharing of patient clinical information and collaborative therapy-related action planning. We determined the proportions of participants with HIV and mental health conditions who were retained in care and the proportion virally suppressed, pre- and post-implementation. Overall, we found a relative 13% improvement in both retention [60% to 68% (p = 0.009)] and viral suppression [79% to 90% (p < 0.001)]. Notable improvements were seen among persons triply diagnosed with HIV, mental illness and substance use [+ 36% (50% to 68%, p = 0.036) and + 32% (66% to 86%, p = 0.001) in retention and viral suppression, respectively]. There were no differences in the proportions of persons adherent to psychiatric medications, pre- to post-implementation, nor were there differences in the proportions of persons retained in care or virally suppressed by psychiatric medication adherence, post-implementation. PCHCM demonstrated that collaborations between community-based pharmacists and medical providers can improve HIV care continuum outcomes among persons with mental health conditions.

Impact of HIV-specialized pharmacies on adherence to medications for comorbid conditions.

OBJECTIVE: To determine if patients using human immunodeficiency virus (HIV)-specialized pharmacies have greater adherence to drugs used to treat comorbid conditions and HIV compared with patients who use traditional pharmacies. DESIGN: Retrospective cohort study, with patients' propensity matched based on pharmacy use: HIV-specialized versus traditional. SETTING: Nationwide pharmacy chain. PARTICIPANTS: Adult patients who filled at least two prescriptions for an antiretroviral therapy (ART). Patients also needed to have at least two prescriptions for an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) or a statin for analyses examining comorbid conditions. MAIN OUTCOME MEASURE: Proportion of days covered (PDC). RESULTS: The adherence analyses for ART, ACE inhibitors/ARBs, and statins included 14,278, 1,484, and 1,372 pairs, respectively. The mean PDC for ART patients using HIV-specialized pharmacies was higher than that for patients using traditional pharmacies (86.20% vs. 81.87%; P <0.0001). Patients taking ACE inhibitors/ARBs in the specialized group also had a higher mean PDC compared with patients in the traditional group (82.61 vs. 79.66; P = 0.0002), as did specialized pharmacy users in the statin group (83.77 vs. 81.29; P = 0.0009). CONCLUSION: HIV patients managed by an HIV-specialized pharmacy have significantly higher adherence to medication for comorbid conditions compared with patients using traditional pharmacies. Patients of HIV-specialized pharmacies also have significantly higher adherence to ART compared with peers using traditional pharmacies.

Evaluation of Medication Therapy Issues, Resolutions, and Adherence Among Persons With HIV in the Pharmacist-Led Patient-Centered HIV Care Model.

OBJECTIVE: To identify medication therapy issues and resolutions and assess their relationship to antiretroviral therapy (ART) adherence among participants of the Patient-Centered HIV Care Model demonstration project. METHODS: Adult persons with HIV (PWH) in the United States were enrolled in the Patient-Centered HIV Care Model from August 2014 to September 2016. Pharmacists conducted regular medication therapy reviews and documented ART and non-ART issues and suggested resolutions. Adherence to ART was calculated using proportion of days covered (PDC), and the mean PDC by the number of ART issues was compared using a generalized linear model with linear trend estimation. RESULTS: The most common ART issue was adherence (57%). Adherence ART issues were resolved by adherence management (48%) or patient education (36%). Participants had a mean of 4.2 ART issues and 6.4 non-ART issues. PDC was 89% for those with 0 ART issues and 73% for those with ≥3 ART issues. Persons with 0 ART issues had an increase in adherence (+8%) in the postperiod, whereas those with ≥3 ART issues had a decrease in adherence (-6%) (P = 0.02) in the postperiod. CONCLUSIONS: Identifying therapy issues could help pharmacists improve care for PWH. Because PWH are an aging population with an increased risk of comorbidities and polypharmacy, pharmacists and providers should collaborate to provide holistic, primary care solutions to address both the number and nature of therapy issues.

Antiretroviral Adherence Level Necessary for HIV Viral Suppression Using Real-World Data.

BACKGROUND: A benchmark of near-perfect adherence (≥95%) to antiretroviral therapy (ART) is often cited as necessary for HIV viral suppression. However, given newer, more effective ART medications, the threshold for viral suppression may be lower. We estimated the minimum ART adherence level necessary to achieve viral suppression. SETTINGS: The Patient-centered HIV Care Model demonstration project. METHODS: Adherence to ART was calculated using the proportion of days covered measure for the 365-day period before each viral load test result, and grouped into 5 categories (<50%, 50% to <80%, 80% to <85%, 85% to <90%, and ≥90%). Binomial regression analyses were conducted to determine factors associated with viral suppression (HIV RNA <200 copies/mL); demographics, proportion of days covered category, and ART regimen type were explanatory variables. Generalized estimating equations with an exchangeable working correlation matrix accounted for correlation within subjects. In addition, probit regression models were used to estimate adherence levels required to achieve viral suppression in 90% of HIV viral load tests. RESULTS: The adjusted odds of viral suppression did not differ between persons with an adherence level of 80% to <85% or 85% to <90% and those with an adherence level of ≥90%. In addition, the overall estimated adherence level necessary to achieve viral suppression in 90% of viral load tests was 82% and varied by regimen type; integrase inhibitor- and nonnucleoside reverse transcriptase inhibitor-based regimens achieved 90% viral suppression with adherence levels of 75% and 78%, respectively. CONCLUSIONS: The ART adherence level necessary to reach HIV viral suppression may be lower than previously thought and may be regimen-dependent.

The 340B discount program: outpatient prescription dispensing patterns through contract pharmacies in 2012.

Section 340B of the Public Health Service Act provides qualified organizations serving vulnerable populations with deep discounts for some outpatient medications. A 2010 regulatory change widely expanded the 340B program's reach, allowing these organizations to contract with retail pharmacies to dispense medications for eligible patients. Little is known about which medications are dispensed by contract pharmacies under the expanded program. We provide the first comparison of 340B prescriptions and all prescriptions dispensed in contract pharmacies. We used 2012 data from Walgreens, the national leader in 340B contract pharmacies. Medications used to treat chronic conditions such as diabetes, high cholesterol levels, asthma, and depression accounted for an overwhelming majority of all prescriptions dispensed at Walgreens as part of the 340B program. A higher percentage of antiretrovirals used to treat HIV/AIDS were dispensed through 340B prescriptions than through all prescriptions dispensed at Walgreens. The majority of 340B prescriptions dispensed at Walgreens originated at tuberculosis clinics, consolidated health centers, disproportionate-share hospitals, and Ryan White clinics. Our results suggest that 340B contract pharmacies dispense medications used to treat Americans' chronic disease burden and disproportionately dispense medications used by key vulnerable populations targeted by the program.

Evaluation of increased adherence and cost savings of an employer value-based benefits program targeting generic antihyperlipidemic and antidiabetic medications.

BACKGROUND: A major employer implemented a change to its employee health benefits program to allow beneficiaries with diabetes or high cholesterol to obtain preselected generic antidiabetic or generic antihyperlipidemic medications with a zero dollar copayment. To receive this benefit, plan beneficiaries were required to participate in a contracted vendor's case management and/or wellness program.  OBJECTIVE: To assess changes in medication adherence and the costs for generic antidiabetic and generic antihyperlipidemic medications resulting from participation in a zero copay (ZCP) program.   METHODS: This was a retrospective pre-post comparison group study, evaluating adherence and cost. Participants using an antihyperlipidemic and/or antidiabetic medication during the study identification period and post-implementation period for the program were considered eligible for the study. Eligible beneficiaries who enrolled in the ZCP program during the post-implementation period were considered participants, while those who did not enroll during this period were considered nonparticipants. ZCP program participants and nonparticipants were matched via a 1-to-1 propensity scoring method using age, gender, comorbidity count, medication type (antihyperlipidemic, antidiabetic, or both), and baseline adherence as matching criteria. The proportion of days covered (PDC) metric expressed as a mean percentage was used to assess adherence to medication therapy, while payer cost was examined using prescription drug utilization expressed as per member per year (PMPY) and cost change per 30 days of medication expressed in dollars.   RESULTS: Among participants who were users of antidiabetic medications, the mean adherence rate was sustained from pre- to post-implementation (81.8% vs. 81.9%); however, it decreased in the matched nonparticipant group (81.9% vs. 73.1%). This difference in mean adherence over time between the participants and nonparticipants was statistically significant (0.1% vs. -8.8%, P less than 0.001). Similar results were found among users of antihyperlipidemics. The mean adherence rate was sustained over time for participants (77.7% vs. 78.3%) but declined over time for nonparticipants (77.6% vs. 70.8%). The difference in mean change over time was statistically significant between participants and nonparticipants (0.6% vs. -6,8%, P less than 0.001). Average prescription costs PMPY increased for participants of the ZCP program during the post-implementation period; however, the increase was not larger than the cost increase among nonparticipants ($581 vs. $584, P = 0.95). Furthermore, among antihyperlipidemics the cost increase post-implementation was actually significantly less for participants than nonparticipants ($51 vs. $143, P less than 0.001).  CONCLUSIONS: Plan sponsors are increasingly evaluating the use of value-based benefit design (VBBD) to change member behavior. This ZCP program used a reduction in cost sharing to incentivize members to use more generic drugs and to enroll in a care management coaching program. The study also demonstrated that a VBBD program can have a positive impact on adherence and cost outcomes among those who participate compared with nonparticipants. 

Impact of HIV-specialized pharmacies on adherence and persistence with antiretroviral therapy.

Patient adherence (the degree to which patients follow their therapeutic regimen as prescribed within a set period of time) and persistence (the time to treatment discontinuation, with a permissible gap) with drug therapy are essential components of HIV/AIDS treatment. Select community pharmacies offer specialized services for HIV/AIDS patients to help combat some of the barriers to adherence and persistence. We assessed adherence and persistence with antiretroviral therapy (ART) for patients using HIV-specialized pharmacies in nine cities from seven states compared to traditional community pharmacy users over a 1-year period. Data were limited to one pharmacy chain. Propensity scoring was used to obtain 1:1 matches for "Specialized" and "Traditional" pharmacy users based on age, gender, number of prescription-inferred chronic conditions (obtained by mapping a patient's prescriptions to the Medi-Span Drug Indications Database), and presence of prescription anxiety and/or depression medication, resulting in 7064 patients in each group. Proportion of days covered (PDC) was used to measure adherence. Specialized pharmacy users had a significantly greater mean (74.1% versus 69.2%, p<0.0001) and median (90.3% versus 86.3%, p<0.0001) PDC. A greater percentage of patients in the Specialized group were able to obtain a PDC of 95% or better (39.3% versus 35.5%). Patients in the Specialized group were significantly more persistent (p=0.0117). Community pharmacies specialized in HIV services may be effective avenues for helping patients achieve greater adherence and persistence with ART. Given the value of specialized community pharmacies, payers should consider implementing policies to encourage the use of such pharmacies for filling ART.

Impact of an online prescription management account on medication adherence.

OBJECTIVES: To assess medication adherence rates of patients utilizing an online prescription management account compared with nonusers. STUDY DESIGN: A retrospective analysis was conducted using de-identified pharmacy claims data from a pharmacy benefit manager covering the period from April 1, 2009, to March 31, 2011. Patients who were continuously eligible throughout the study period and that had at least 1 prescription fill for any of the 8 therapeutic groups examined in the study were selected for inclusion. METHODS: Adherence was assessed by measuring the proportion of days covered (PDC). Propensity score matching was utilized to minimize differences in age, gender, chronic condition score, copay, household income, and urban locality between the users and nonusers groups. Results were reported for all therapeutic groups combined, as well as by individual therapeutic group. RESULTS: Overall, patients utilizing the online account had a significantly higher weighted average PDC (73.19% vs 61.64%, P <.0001). Users also had a higher average PDC for each individual therapeutic group, although the beta-blocker group was not statistically significant. The percentage of patients achieving an average PDC of >80% was also found to be greater in the users group across each therapeutic group and overall. CONCLUSIONS: Patients who utilized an online prescription management account had higher rates of medication adherence as compared with nonusers. Additional studies are needed to assess which specific components of the prescription management account have the biggest impact on adherence.