William H. Shrank, MD, MSHS; Niteesh K. Choudhry, MD, PhD; Michael A. Fischer, MD, MPH; Jerry Avorn, MD; Mark Powell, MA, MEd; Sebastian Schneeweiss, MD, ScD; Joshua N. Liberman, PhD; Timothy Dollear, MS; Troyen A. Brennan, MD, JD; M. Alan Brookhart, PhD
Grant Support: By a research grant from CVS Caremark. Dr. Shrank is supported by a career development award from the National Heart, Lung, and Blood Institute (HL-090505), and Dr. Brookhart is supported by a career development grant from the National Institutes of Health (AG-027400).
Potential Conflicts of Interest: Dr. Shrank: Grants (money to institution): National Institutes of Health (National Heart, Lung, and Blood career development award), CVS Caremark. Drs. Choudhry, Fischer, Avorn, and Brookhart: Grants (money to institution): CVS Caremark. Dr. Schneeweiss: Grants (money to institution): CVS Caremark. Board membership: HealthCore. Consultancy: WHISCON, RTI Health Solutions, The Lewin Group. Grants/grants pending: Pfizer. Drs. Liberman, Dollear, and Brennan: Employment: CVS Caremark. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1125.
Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.
Requests for Single Reprints: William H. Shrank, MD, MSHS, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Shrank, Choudhry, Fischer, Avorn, and Schneeweiss: Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120.
Mr. Powell: Harvard University, Faculty of Arts and Sciences, Center for American Political Studies, 1737 Cambridge Street, Cambridge, MA 02138.
Dr. Liberman and Mr. Dollear: CVS Caremark, 11311 McCormick Road, Suite 230, Hunt Valley, MD 21031.
Dr. Brennan: CVS Caremark, One CVS Drive, Woonsocket, RI 02895.
Dr. Brookhart: Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, McGavran-Greenberg, CB #7435, Chapel Hill, NC 27599-7435.
Author Contributions: Conception and design: W.H. Shrank, N.K. Choudhry, M.A. Fischer, J. Avorn, T.A. Brennan, M.A. Brookhart.
Analysis and interpretation of the data: W.H. Shrank, N.K. Choudhry, M.A. Fischer, J. Avorn, M. Powell, S. Schneeweiss, J.N. Liberman, T. Dollear, M.A. Brookhart.
Drafting of the article: W.H. Shrank, N.K. Choudhry, M.A. Brookhart.
Critical revision of the article for important intellectual content: W.H. Shrank, N.K. Choudhry, M.A. Fischer, J. Avorn, S. Schneeweiss, J.N. Liberman, T.A. Brennan.
Final approval of the article: W.H. Shrank, N.K. Choudhry, M.A. Fischer, J. Avorn, S. Schneeweiss, T.A. Brennan, M.A. Brookhart.
Provision of study materials or patients: J.N. Liberman.
Statistical expertise: W.H. Shrank, N.K. Choudhry, M.A. Fischer, M. Powell, S. Schneeweiss, M.A. Brookhart.
Obtaining of funding: W.H. Shrank, N.K. Choudhry, J. Avorn.
Administrative, technical, or logistic support: W.H. Shrank, J. Avorn, J.N. Liberman, T. Dollear, T.A. Brennan.
Collection and assembly of data: W.H. Shrank, J.N. Liberman, T. Dollear.
Shrank W., Choudhry N., Fischer M., Avorn J., Powell M., Schneeweiss S., Liberman J., Dollear T., Brennan T., Brookhart M.; The Epidemiology of Prescriptions Abandoned at the Pharmacy. Ann Intern Med. 2010;153:633-640. doi: 10.7326/0003-4819-153-10-201011160-00005
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Published: Ann Intern Med. 2010;153(10):633-640.
Picking up prescriptions is an essential but previously unstudied component of adherence for patients who use retail pharmacies. Understanding the epidemiology and correlates of prescription abandonment may have an important effect on health care quality.
To evaluate the rates and correlates of prescription abandonment.
Cross-sectional cohort study.
One large retail pharmacy chain and one large pharmacy benefits manager (PBM) in the United States.
Prescriptions bottled at the retail pharmacy chain between 1 July 2008 and 30 September 2008 by patients insured by the PBM were identified. Pharmacy data were used to identify medications that were bottled and either dispensed or returned to stock (RTS) or abandoned. Data from the PBM were used to identify previous or subsequent dispensing at any pharmacy. The first (index) prescription in a class for each patient was assigned to 1 of 3 mutually exclusive outcomes: filled, RTS, or RTS with fill (in the 30 days after abandonment, the patient purchased a prescription for a medication in the same medication class at any pharmacy). Outcome rates were assessed by drug class, and generalized estimating equations were used to assess patient, neighborhood, insurance, and prescription characteristics associated with abandonment.
10 349 139 index prescriptions were filled by 5 249 380 patients. Overall, 3.27% of index prescriptions were abandoned; 1.77% were RTS and 1.50% were RTS with fill. Patients were least likely to abandon opiate prescriptions. Prescriptions with copayments of $40 to $50 and prescriptions costing more than $50 were 3.40 times and 4.68 times more likely, respectively, to be abandoned than prescriptions with no copayment (P < 0.001 for both comparisons). New users of medications had a 2.74 times greater probability of abandonment than prevalent users (P < 0.001), and prescriptions delivered electronically were 1.64 times more likely to be abandoned than those that were not electronic (P < 0.001).
The study included mainly insured patients and analyzed data collected during the summer months only.
Although prescription abandonment represents a small component of medication nonadherence, the correlates to abandonment highlight important opportunities to intervene and thereby improve medication taking.
Osama S.M. Amin MD, FACP
Sulaimaniya General Teaching Hospital
November 17, 2010
Prescriptions Abandoned...? Should we re-check them all the time?
Many thanks to Shrank et al for conducting this study and highlighting the subject, and a special gratitude goes to Annals of Internal Medicine for publishing it!
This is a global problem, and many pharmacies are nowadays employing non-pharmacists (and people who are not linked by any means to the medical life) to do the work. This increases the burden and mistakes, no doubt. On the other hand, sits the generic or "commercial" name of this or that medication.
And, the majority of us blame the patient/caregiver about the non- compliance issue. Is it ethical that every physician re-checks the dispensed medication? And if a "fatal" mistake happens, should he/she report this?
Jeanette L. Altavela
Greater Rochester Independent Practice Association
November 21, 2010
This Abstract Leads to Deceptive Results
I read this article, " The Epidemiology of Prescriptions Abandoned at the Pharmacy" by Shrank ,et al, .with much interest as I am involved in addressing barriers to medication adherence. However, I was quite surprised by which of the 6 statistically significant correlates related to abandoned prescriptions were chosen to be included in the abstract. In the results section of the abstract it stated, "prescriptions delivered electronically were 1.64 times more likely to be abandoned than those that were not electronic (P < 0.001)". I found the methods and data within this study did not support the ability to compare the rate of abandonment of electronic vs. non-electronic prescriptions in reality. To make an accurate comparison of electronic vs. non-electronic, one would have to include all "non-electronic" prescriptions, and determine where they ended up. This study only had access to what they referred to as "non- electronic" prescriptions (be it a faxed, phoned in, or written prescription) in one of the many retail pharmacy chains in the USA, and thus was unable to follow all non-electronic prescriptions from inception (i.e. from the point they were "created") to their final destination. Many written prescriptions never even make it to a pharmacy, thus the abandonment rate of "non-electronic" prescriptions in this study has a risk of being underestimated. This study was only comparing the electronic vs. non-electronic prescriptions, that landed in CVS pharmacies only and did not take into account any paper prescriptions that never arrived at a CVS pharmacy. That being the case, I read through the limitations of the study, expecting to see this issue mentioned as a limitation, and found nothing addressing that. So, it is with dismay, that I have physician colleagues reading this abstract, and believing the results are true at face value, and then I have to explain that the comparison of electronic vs. non-electronic cannot actually be measured with the data presented. I explain that there is no way for this team of researchers to actually know the true denominator of non-electronic prescriptions and that I wished this limitation was at least addressed in the discussion section of this article. After an email conversation with Dr. Shrank, I realize it was not his intention to mislead and he supports electronic prescribing. I still let him know that I think the results seem to imply that electronic prescriptions are filled less often than non -electronic prescriptons (and may imply that "paper" is better). I think the results can be misleading to readers, particularly since this limitation was not expressed in the discussion of the article.
Michael Van Ornum
Health Information Management Systems Society
November 22, 2010
E-Prescribing gets a Bad Rap
A comparison of electronically prescribed medications with paper prescribed prescriptions in a medical office is the holy grail of e- prescribing research. The problem in realizing this comparison is the extreme difficulty of capturing all non-electronically prescribed medications. Providers not only have paper, but also have fax, phone, and surrogates to deliver the orders to the pharmacy. In this recent article "The Epidemioligy of Prescriptions Abandoned at the Pharmacy", Dr. Shrank implies a solution to this dilemma of measurement without disclosing any supporting evidence when he states, "Prescriptions delivered electronically to the pharmacy were almost 65% more likely to be abandoned than those delivered by other means." Implied in this statement is that prescriptions delivered by other means are less likely to be abandoned, and therefore would be a preferred delivery choice. What is not underscored is the percent of prescriptions that never get delivered to the pharmacy by the patient. The comparison of prescriptions delivered electronically does not have a fair comparator with those delivered by other means since those prescriptions were already biased towards being filled by the fact they were submitted to the pharmacy. The patient's willful act of submission of a prescription to the pharmacy requires a modicum of engagement in the medical therapy in contrast to the patient who receives a prescription but never submits it for filling at the pharmacy. Please acknowledge that prescribers should not interpret this statement to imply that electronic prescriptions are inferior to other means of delivery, nor use this article to justify avoiding e-prescribing technology.
William H. Shrank
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's
January 11, 2011
Response to Van Ornum and Altavela
We appreciate the responses to our article about prescriptions abandoned at the pharmacy (1), and must clarify several issues. We did not study prescription fulfillment - rates that prescriptions written were ultimately filled and purchased by patients. Our measure of abandonment was the rate prescriptions were delivered to the pharmacy and filled, and then subsequently returned to stock after a patient failed to purchase. This represents a small slice of the overall problem of medication non- adherence. However, it is an important locus in the medication acquisition pathway, providing a unique opportunity to intervene. In addition, these prescriptions are a source of inefficiency, as there is a cost attributable to each abandoned prescription.
There are numerous potential advantages of electronic prescribing, including improved safety, quality and cost-effectiveness medication use. However, it is essential to thoroughly vet the benefits and unintended consequences. Comments by Van Ornum and Altavela incorrectly suggest that we implied that electronic prescribing leads to greater rates of overall nonadherence. In our discussion we highlighted the fact that non- electronically transmitted prescriptions are less likely to ever make it to the pharmacy. Automatic, electronic transmission of prescriptions, by definition, enriches the pool of prescriptions for patients who never would have hand-delivered a prescription and who would have become non- adherent before entertaining the possibility of abandonment. As a result, electronic transmission of prescriptions will increase the likelihood that pharmacists receive and prepare medications for purchase, increasing abandonment.
Even among electronically-written prescriptions, some are transmitted electronically to the pharmacy and others are printed and handed to the patient. We noted, "some patients who receive electronic prescriptions do not have to hand-deliver the prescription to the pharmacy or otherwise initiate the fill request themselves. Because they lack a patient-initiated step, electronic prescriptions may be more likely to be delivered to the pharmacy for patients who never intended to ?ll the prescription." As noted in the discussion, this can lead to greater inefficiency and costs for the pharmacy, and underscores the fact that medication lists may not reflect medication use. We provided pharmacists with a simple decision rule to assess abandonment risk and enhance pharmacy efficiency.
We never suggested that electronic prescribing is associated with reduced adherence overall. Research from this team suggests just the opposite (2). We noted that electronic prescribing may encourage cost- conscious prescribing and called for further study of e-prescribing systems to improve pharmacy efficiency and enhance documentation and quality of care.
1. Shrank WH, Choudhry NK, Fischer MA, Avorn J, Powell M, Schneeweiss S, Liberman JN, Dollear T, Brennan TA, Brookhart MA. The epidemiology of prescriptions abandoned at the pharmacy. Annals of Internal Medicine. 2010 Nov 16;153(10):633-40.
2. Fischer MA, Choudhry NK, Brill G, Avorn J, Schneeweiss S, Liberman J, Hutchins D, Brennan TA, Shrank WH. Prescribing in compliance with patient formularies increases primary adherence in patients receiving electronic prescriptions. Journal of General Internal Medicine (Supplement) 2010; S360.
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