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Why patients don't pick up prescriptions.

The Problem

A 63-year-old female with a history of coronary artery disease, hypertension, and type 2 diabetes, as well as a 40-pack-year history of smoking, presents to you for follow-up of her multiple medical issues. She wishes to stop smoking. She smokes one pack per day. She has used varenicline, but developed nausea unmitigated by food or water intake and she had to discontinue it. You decide to start her on a 21-mg nicotine patch, nicotine gum, and a nicotine inhaler. You write the prescription and fax it to her pharmacy. After 6 months, you see her again for her multiple medical issues and she tells you that she never picked up the prescription. Immediately, you wonder how many other prescriptions you have written and faxed that have not been picked up by your patients.

The Question

What variables are associated with abandonment of prescriptions at the pharmacy?

The Search

You open PubMed (www.pubmed.gov) and enter the terms "prescription AND abandonment."

Our Critique

This is a well-conducted, timely, and fascinating study. The four strongest predictors of medication abandonment at the pharmacy are high co-payment, young age, new user, and an electronic prescription.

Clinical Decision

In the future, you will consider writing prescriptions and handing them to the patient, especially when prescribing a new medication to a young patient and when prescribing smoking cessation medications, which require a higher level of patient commitment than do other classes of medications. You also will inform patients about medication cost so that "sticker shock" does not prevent them from purchasing prescribed medications, and will explore alternatives before they leave the office.

JON O. EBBERT, M.D., AND ERIC G. TANGALOS, M.D.

DR. EBBERT and DR. TANGALOS are with the Mayo Clinic in Rochester, Minn. They report having no conflicts of interest. To respond to this column or suggest topics, write to them at imnews@elsevier.com.

RELATED ARTICLE: The Evidence

Shrank WH, et al. "The epidemiology of prescriptions abandoned at the pharmacy," (Ann. Intern. Med. 2010;153:633-40).

* Data sources. Data were provided by a large retail pharmacy chain. Pharmacy data contained all prescriptions, mode of transmission to the pharmacy (for example, electronic), and whether the prescription was bottled and returned to stock. Insurance claims were matched and analyzed.

* Study period and cohort construction. All filled prescriptions that were either abandoned or purchased were identified during a 3-month period in calendar year 2008. Recorded retail transactional data included coverage and copayments.

* Outcomes. Three prescription outcomes were possible: filled prescription, indicating that it was purchased; returned to stock (RTS), indicating prescription abandonment, which typically happens to medications that are not picked up within 14 days; or RTS with an indication that the prescription was abandoned but that the patient purchased a prescription in the same class at another pharmacy.

* Characteristics of patients and prescriptions. A prescription was considered "new" if no other prescriptions in the medication class had been filled in the 6 months before the index date. Data on patient demographics, copayment amount, generic status, source of insurance, how the prescription was transmitted, and whether the medication was for an acute or chronic condition were available.

* Findings. Almost 10.5 million prescriptions were filled by nearly 5.5 million patients during the identification period. Patients averaged 47 years of age and 60% were female. Abandonment occurred with 3.3% of prescriptions, 1.8% were RTS, and 1.5% were filled at some other pharmacy in that time frame ("RTS with fill"). Opiates and antiplatelet medications were least likely to be RTS (1.0%) and 0.9%, respectively). Antihypertensives, oral diabetic medications, and statins had low abandonment rates. Among daily-use therapies, higher rates of RTS were observed for proton pump inhibitors (2.6%), asthma medications (3.5%), and insulin (2.2%). Cough/cold/allergy and dermatologic agents were the most likely to be RTS (3.6% and 3.0%, respectively).

The amount of the copayment was strongly associated with abandonment, such that prescriptions with copayments lower than $10 were abandoned 1.4% of the time, compared with 4.5% of the time for copayments greater than $50. Compared with prescriptions with no copayments, prescriptions with copayments of $40.01-$50.00 had a 3.4-fold greater probability of being abandoned; prescriptions costing more than $50.01 had a 4.7-fold greater probability of being abandoned. Abandonment was greater for brand-name medications than for generics. Abandonment was more likely to occur among people living in areas with a lower median income, Medicaid beneficiaries (compared with individuals with employer-sponsored insurance), young adults (aged 18-34 years), patients with more comorbid conditions, new users, and users of medications for acute conditions (compared with chronic ones). Notably, prescriptions that were delivered electronically had a 64% increase in the probability of being abandoned.
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Article Details
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Title Annotation:MINDFUL PRACTICE
Author:Ebbert, Jon O.; Tangalos, Eric G.
Publication:Internal Medicine News
Geographic Code:1USA
Date:Jan 1, 2011
Words:795
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