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E-Prescribing With Decision Support Is Associated With Improvements in Medication Adherence

This study evaluates whether provider adoption and use of formulary decision support for e-prescribing are directly associated with significant prescriber and patient behavior change.
Published Online: Aug 17,2016
Jaime Y. Smith, MAE; R. Scott Leslie, MPH, PhD; Bimal V. Patel, PharmD, MS; Clark Kucharski, BS; Seth B. Joseph, MBA; and Max Sow, MBA
Objectives: To evaluate whether provider adoption and use of the formulary decision support element of e-prescribing were directly associated with significant prescriber and patient behavior change.
Study Design: Retrospective, observational prepost study comparing a treatment group with a control group.
Methods: Pharmacy fill information and provider enrollment records from January 2009 to December 2011 were used to compare fill volumes—primary fill and subsequent refill volume by retail and mail order fulfillment channels—of prescribers who had adopted e-prescribing (treatment group) with those who had not (control group). Propensity scores were used to match treatment and control groups by baseline prescribing patterns. Primary outcomes of interest were prepost differences for 90-day retail fills, initial fills (primary adherence), and subsequent refills.
Results: E-prescribers demonstrated significantly higher average increases in 90-day retail fills (+2.8 fills per provider, P <.001), primary adherence (+12.0 fills per provider, P <.001), and subsequent adherence (second fill: +4.5 fills per provider, P <.001; and third fill: +2.4 fills per provider, P <.001) compared with non–e-prescribers.
Conclusions: Provider adoption and use of e-prescribing applications with formulary decision support were associated with significant prescriber and patient behavior change in a large, nationally representative population. E-prescribing adoption was positively associated with prescribers’ selection of longer supply prescriptions and improvements in adherence. E-prescribing infrastructure may allow for additional provider messaging opportunities designed to improve quality of care and patient outcomes.
Am J Pharm Benefits. 2016;8(4):133-140

Pharmacy benefit managers (PBMs) are critical stakeholders in the healthcare industry, responsible for administering prescription benefit programs for the vast majority of insured Americans. Prescription drug spending represents 10% of total healthcare expenditures, or roughly 1.8% of US gross domestic product.1

Importantly, prescription drugs are first- or second-line treatments for many chronic diseases associated with an outsized portion of healthcare spend.2,3 Appropriate and persistent use of prescription drugs to treat chronic diseases has also been demonstrated to reduce downstream medical expenditures,4 achieving substantial cost savings.5,6

In addition, pharmacies are the most frequently utilized healthcare service, with the average patient filling nearly 4 times as many prescriptions as the number of their visits to office-based physicians.7,8 Given these facts and additional demographic context—an aging population with increasing prescription drug use on a per capita basis9,10—it becomes clear that PBMs can play a significant role in the current healthcare reform landscape.11,12

PBMs are adopting benefit design strategies that reflect the broader healthcare trend of aligning payment to value and outcomes. A common theme among the evolving strategies is an effort to address and improve patient adherence to medication. Due to their position of processing prescription claims, PBMs are in a unique position to have the most comprehensive view of a patient’s prescription treatment regimen.
PBMs can leverage claims, eligibility, pharmacy data, and provider data to understand prescribing patterns and patient behavior by identifying gaps in care and suboptimal adherence, and potentially to effect positive behavior change relating to medication adherence through the timely delivery of information to providers, patients, and pharmacies.
Surescripts is a health information network that connects PBMs, pharmacies, and providers using electronic health records (EHRs) for the purpose of enabling real-time electronic prescribing. Through Surescripts, PBMs can electronically deliver prescription formulary, eligibility, and co-pay information to providers using a certified EHR. MedImpact Healthcare Systems, Inc, is one such PBM, managing pharmacy benefits for more than 47 million individuals nationwide, connected to the Surescripts network. Provider use of the benefit information through Surescripts is associated with increased levels of preferred brand and generic prescribing, resulting in lower co-pays that are in turn linked to improved adherence.13,14
Surescripts also provides PBM-supplied decision support information about availability of retail 90-day supply and mail-order benefits, both of which have been linked to improved adherence.15,16 The ability of providers to route prescriptions electronically provides an auditable trail between what the provider prescribed and whether the patient filled the prescription at the pharmacy, addressing a current challenge with quality measures relating to primary adherence.17,18
Additionally, provider use of electronic prescribing (e-prescribing) is a core measure in the EHR Incentive Program, a federal incentive program to promote provider adoption and meaningful use of EHRs.19 The e-prescribing core measure requirement is currently limited to the routing component of e-prescribing; however, e-prescribing infrastructure allows numerous opportunities for formulary decision support and clinical messaging.
Current widely used methods of measuring medication adherence (such as proportion of days covered or medication possession ratio) rely on the presence of a claim for the first prescription fill, which is available only if the patient successfully picked up the initial prescription from the pharmacy. A challenge with these methods is that as many as 28% of first-fill prescriptions are abandoned before they reach the pharmacy, and therefore, such measures may be overstating true levels of medication adherence.20
Our study is novel in that we sought to understand whether provider adoption and use of the formulary decision support element of e-prescribing was directly associated with improved medication adherence as indicated by increases in the number of claims for 90 days’ supply, first fill, and subsequent refills. We did this by pairing data from Surescripts’ provider network and MedImpact’s pharmacy information.
We investigated 3 core questions: first, we assessed whether e-prescribing resulted in prescribing behavior change, as indicated by selection of 90-day prescriptions; second, whether e-prescribing is associated with an increase in primary adherence, as indicated by the number of claims for first-fill prescriptions; and third, whether there was a discernible subsequent impact on second and third medication fills.