'Primary medication non-adherence'--a new measure for prescription abandonment

An issue brief just published by the Network for Excellence in Health Innovation (NEHI; Boston) highlights both the continuing problem of medication adherence, and how a changing healthcare system—specifically, the prevalence of e-prescribing—provides deeper detail on the problem. It also raises the possibility that, with the appropriate incentives in place, community pharmacy could become a more effective means of addressing non-adherence.

As has long been known, patients’ adherence to prescribed therapies is poor, with non-adherence rates as high as 50% in some cases. Non-adherence has been measured by refill rates; by calculation of “medication possession ratio,” (a measure of the time interval between refills) and by abandonment—filled prescriptions that are never picked up at the pharmacy. Now, however, analysis by NEHI and by the Pharmacy Quality Alliance (a consortium of healthcare stakeholders) shows that the records of prescriptions within e-prescribing systems, which eliminate the patient hand-carrying a written prescription to a pharmacy, allows for a more precise measurement: primary medication non-adherence (PMN)—when a patient is prescribed a medication for the first time but fails to obtain and take it. PMN sounds like abandonment, but abandonment traditionally entailed the written prescription being delivered to the pharmacy (and is therefore sometimes caused by the unavailability of the medication at the moment when the patient appeared at the pharmacy). PMN is also focused primarily on chronic conditions and not acute care.

With the precision of the PMN measurement (which ranges upward of 30% of prescriptions according to recent analysis), all stakeholders in healthcare have a better handle on what has been called the “blind spot” in adherence. What to do about it? As the issue brief points out, various stakeholders, including health systems being evaluated by the Medicare Star program (a measure of health-system performance), have real incentives to improve PMN. Community pharmacies are well-positioned to play a role, but “the pharmacy sector does not currently enjoy advantages and incentives enjoyed by other stakeholders with a potential interest in closing the PMN gap.” NEHI recommends that payers and healthcare providers, among others, work out how to coordinate the incentives that they receive, with potential incentives for the pharmacy sector.

Meanwhile, there are still operational issues to be resolved: the lack of interoperability among electronic health-record (EHR) systems, and the dropoff between physicians with access to EHRs, and the volume of prescriptions that they still write by hand.

The paper is available at NEHI’s website.