Medication Adherence: Practical Insight for Underwriting Metropolitan Underwriting Discussion Group Intercontinental Times Square New York City Monday, Jan. 26 th, 2015 Scott Whitmore, R.Ph. Director of Clinical Services Milliman IntelliScript Brookfield, Wisconsin 1
Agenda Define medication adherence Rx non-adherence risk factors Underwriting implication of non-adherence with key diseases Impact of non-adherence on relative mortality for some select pharmacotherapies Illustrate how a prescription rule engine can analyze medication adherence 2
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Definition of medication adherence The degree to which the person s behavior corresponds with the agreed recommendations from a health care provider. World Health Organization 4
Medication adherence consists of two elements: Compliance taking the medication as intended Persistence maintenance of medication use over time The preferred medical term is adherence The Underwriting Implications of Rx Nonadherence George, Hank 2013 5
What is the difference between primary and secondary nonadherence? Primary nonadherence is the failure to fill a prescription Secondary nonadherence is when a patient fails to take the drug as prescribed Refill patterns on Rx histories and secondary nonadherence Mortality risk is greater primary vs secondary George, Hank The Underwriting Implications of Rx Nonadherence 2013 6
Secondary nonadherence typically manifests within 6 months after filling a prescription the first time Agarwal, Chapman and Benner, Perreault and Lamarre, Serna 7
What are typical nonadherence rates? 53% of U.S. patients take less of the medication than is prescribed American Heart Association: Statistics you need to know. http://www.americanheart.org/presenter.jhtml?identifier=107 Accessed November 21, 2007. 8
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Nearly three in four Americans fail to follow their doctor s instructions for taking prescription drugs, a problem that is associated with 125,000 deaths each year.. Varun Vaidya, PhD, et al University of Toledo College of Pharmacy Patient Preferences and Adherence 7(2013):21 10
Failure to adhere to prescribed medications matters. Increased hospitalization Poor health outcomes Increased costs Decreased quality of life Patient death Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. JAMA 2002;288:455-461 11
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Why don t patients adhere to their medication therapy? Failure to understand the need for the medication Complex therapies Side Effects High out-of-pocket costs Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002;288:455-461 13
Select nonadherence implications for risk assessment and insurability Clinical outcomes Absenteeism and disability Treatment intensification Provider recognition of nonadherence Patient exaggeration Specialist factor >65 years meds identification Medicare vs other insurers George, Hank. The Underwriting Implications of Rx Nonadherence 2013 14
Overall Risk Factors for Nonadherence YELLOW FLAGS Age 35 and under Age 70 and over Divorced, separated or widowed Less than 12 years of formal education Low Income Taking multiple daily doses Fear of side effects Frequent business travel Negative perceptions about the drug or the need for taking it Heavy use of potent pain-killing drugs Severe insomnia and other sleep disorders George, Hank The Underwriting Implications of Rx Nonadherence 2013 15
Overall Risk Factors for Nonadherence RED FLAGS Major / persistent side effects Cigarette smoking Psychiatric disorders Type D personality Living alone Lack of social support Cognitive dysfunction ADL and IADL deficits Substance Abuse history Polypharmacy (5+ meds) Not keeping medical appointments Not having recommended medical tests Not wearing seat belts Fair or poor self-rated health George, Hank. The Underwriting Implications of Rx Nonadherence 2013 16
Underwriters using prescription histories are well served by checking refill rates when applicants have one RED FLAG or two YELLOW FLAG risk factors The Underwriting Implications of Rx Nonadherence George, Hank 2013 17
Adherence to statins after two years, by condition Percent of patients continually refilling Rx 50% 40% 30% 20% 10% 0% 40% Acute coronary syndrome 36% Chronic coronary artery disease 24% Primary prevention Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002;288:462-467 18
Antihyperlipidemic Adherence Rates % Adherence Bile Acid Seq. Fibric Acid Deriv. Statins Zetia Niacin Omega3 70 67.4% 80.3% 81.1% 84.1% 79.6% 68.7% 80 57.5% 70.4% 71.7% 73.9% 70.5% 58.6% 90 45.0% 54.6% 56.1% 56.6% 55.3% 43.8% Milliman applicant data from Jan. 1, 2012 thru Apr. 30, 2012 19
Statin nonadherence fuels excess mortality Based on 10 prospective studies, all-cause mortality was 45% lower in adherent patients 1 In new clinical outcomes analysis, all-cause mortality was 40% less in patients with high statin adherence 2 Adjusted hazard ratio for all-cause mortality was 2.7-fold greater on subjects non-adherent to statins 3 1 Simpson. British Medical Journal. 333(2006):15 2 Degli Esposti. Clinical Therapeutics. 34(2012):190 3 Allonen. Clinical Cardiology. 35(2012):E22 20
What are the nonadherence rates to drugs commonly used for CV disease? Drug Class Nonadherence After 1 Year Aspirin 29% to 57% All-Cause Mortality Hazard Ratio Beta-blockers 29% to 57% 1.5 Calcium channel 28% (one study) blockers Statins 26% to 59% 1.9 ACE Inhibitors 22% to 55% 1.7 Clopidogrel 13% to 33% George, Hank. The Underwriting Implications of Rx Nonadherence 2013 21
Additional CV therapies sensitive to adherence Antiarrhythmics Warfarin for A-Fib Dig for CHF or A-Fib Statin or antithrombotic agents used post-stroke The literature supports that there is substantial mortality due to nonadherence in applicants with a history of cardiac and other circulatory events..refill data should always be referenced in these cases. George, Hank. The Underwriting Implications of Rx Nonadherence 2013 22
What are nonadherence rates in chronic lung diseases? COPD ranges from 30%-60% RED FLAGS include smoking, younger age, major depression, > TID dosing, asymptomatic Asthma is at least 30% Researchers found 573 asthmatics self reported an 85% nonadherent rate RED FLAGS include pediatric patients and being asymptomatic George, Hank. The Underwriting Implications of Rx Nonadherence 2013 23
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Failure to follow treatment recommendations is a widespread problem in type-2 diabetics. Primary nonadherence is 3% to 31% Secondary nonadherence is 37% to 51% HbA1-c was 10% lower in adherence diabetics In T2DM Rx nonadherence is # 2 adherence related reason for hospitalization after depression. George, Hank. The Underwriting Implications of Rx Nonadherence 2013 25
Adherence significantly impacts relative mortality on at least five select therapies. Drug Category Adherent RM Non Adherent RM Difference in RM Antidiabetic Agents (Oral) 145% 192% 47% Antidepressants 127% 148% 21% Antihyperlipidemics 92% 115% 23% Antihypertensives 101% 152% 51% Antipsychotics/Antimanics 203% 247% 44% Based on 2012 Milliman Mortality & Adherence Studies 26
Depression is the #1 RED FLAG for Nonadherence among every 100 noncompliant patients, on average of 63.5 can be expected to be depressed as compared to 36.5 not depressed M. Robin DiMatteo, PhD, et al Op. Cit. Overall, about half of depressed individuals believe they can stop their antidepressants as soon as they begin to feel better and that drugs can be taken as required Alex J. Mitchell, MB, MSC, et al Op. Cit. 27
Nonadherence potpourri Nonadherence in the elderly 24% increase in all-cause mortality Placebo effect Nonadherence to placebo has the same impact as nonadherence to medication Healthy Adherer Effect Healthy behavior in general increases adherence George, Hank. The Underwriting Implications of Rx Nonadherence 2013 28
Adherence Measurement Options Drug claims data Efficient, generally accurate, potential data gaps Interviews Generally not accurate but efficient Pill Counts, Surveys, Drug Assays 29
Opportunity to evaluate medication adherence is increasing. Survey of Life insurers: Usage: 41% in 2007... 77% in 2012 71% reported increased use of Rx Rx histories significantly impact decisions Hank George Survey, 2012 Simplified Issue Survey (96 companies reporting) Hank George Survey, November 2010 Survey (99 companies reporting) 30
Adherence can be estimated based on refill patterns 31
A graphic display can help 32
RxRules can automate the calculation of adherence. Rx Data RxRules RxRules Interpretation Conditions Severity Guidance Rule variables: Indication / Therapeutic class Drug combinations Red / Yellow / Green Fill timing Fill counts Dosage Physician specialty Gender / Age Other rules 33
Medication Possession Ratio (MPR) MPR = Sum of days supply for all fills in period Number of days in period Example: Applicant has 3 fills of a once per day drug over 4 months Total number of tablets in possession = 3 x 30 tabs = 90 tabs Total number of days during measurement period =4 x 30 days =120 days MPR = 90 tabs = 75% 120 days 34
RxRules Calculates Adherence Rates Using MPR 35
Closing Observations: Nonadherence rates are disturbingly high. Nonadherence leads to poor outcomes and excess mortality. Underwriters should assess RED and YELLOW risk factors. Depression is the most consistent reason for nonadherence. Rules engines can facilitate consistent ID of adherence. RxRules 36
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Questions? 38
The Underwriting Implications of Rx Nonadherence Hank George www.rxhistories.com Scott Whitmore, RPh Milliman IntelliScript 262-641-3540 scott.whitmore@milliman.com 39