Impact of an antidepressant adherence program in a managed care organization

1. Kara Zivin Bambauer, PhD Stephen Soumerai, ScD Alyce Adams, PhD Fang Zhang, PhD Rick Weisblatt, PhD Neil Minkoff, MD Andrea Grande, RPh Dennis Ross-Degnan, ScD Impact of an antidepressant adherence program in a managed care organization Harvard Pilgrim Health Care and Harvard Medical School

2. Background • The burden of depression is substantial • Effective medications are available to treat depression • Non-adherence to antidepressants remains a substantial problem • Harvard Pilgrim Health Care (HPHC) sought to improve quality of care for depression using available electronic data

3. Objectives • To evaluate the effectiveness of providing faxed feedback to physicians regarding patient refill behavior • Does the proportion of patients who are potentially non-adherent to treatment decrease after the policy? • Does the proportion of days within a treatment episode without antidepressant coverage decrease after the policy?

4. Content of Fax • Introduction: This is a clinical reminder to assist physicians who are treating patients for Major Depressive Disorder (MDD) • Explanation: There are 3 quality of care measures for depression treatment • Summary: information on antidepressant compliance • Symptoms usually remit in 4-6 weeks • Therapy should be continued for 6 months • Only 40% of patients of patients adhere to antidepressant treatment • Closing: Your patient (insert name) has gone more than 10 days without antidepressant treatment (medication name, dose, quantity)

5. Antidepressant Compliance Program (ACP) Definitions • Adherent: antidepressant prescription refilled within 10 days of an expected refill • If not, a fax is sent to the prescribing physician • Potentially non-adherent: antidepressant prescription refilled more than 10 days and less than 30 days after an expected refill • Failure: antidepressant prescription not refilled within 30 days of an expected refill

6. Assumptions Underlying ACP • The prescribing physician receives the fax • The physician makes contact with the patient • A physician-patient conversation occurs that effectively deals with the reasons for patient non-adherence • The patient subsequently refills the antidepressant prescription in a timely manner

7. Inclusion Criteria • All HPHC members were eligible • All types of providers were included • Each patient needed to be enrolled for 6 months before and 6 months after first antidepressant use • Patients were included who used a select subset of antidepressants usually indicated for treatment of depression • New users of antidepressants (no use in previous 100 days) • First episode of antidepressant treatment for each person • Age ≥ 18

8. Timeline

9. Methods • Interrupted time-series (ITS) analysis using SAS PROC AUTOREG • Used to evaluate rates of change in adherence due to the ACP • Look at slope and level changes • ITS is one of the strongest quasi-experimental designs for studying policy changes

10. Characteristics of Study Participants (N=13,128) • Mean age (sd): 42 (11) • Gender: 69% female • Policy Variables • Adherent: 18% • Potentially non-adherent: 29% • Failure: 53% • No significant differences in pre-policy and post-policy patients

11. Percent of Non-Adherent Patients Who Proceed to Adherence Failure Percent Adherence Failures Pre-ACP period First year of ACP Phase-in period

12. Mean Percent of Treatment Days Not Covered Percent Treatment Days Uncovered Pre-ACP period First year of ACP Phase-in period

13. Limitations and Implications • Electronic reminder systems, while popular, may not improve patient adherence • Success of such interventions requires a complex chain of events to occur • We cannot determine from electronic data whether communication between physicians and patients addresses reasons for patient non-adherence • Stand alone interventions targeting adherence are not successful

14. Conclusions • The ACP was not successful at increasing antidepressant adherence rates in HPHC members • Additional research should re-examine assumptions underlying the ACP to identify ways to improve future antidepressant adherence interventions • Effectiveness of electronic interventions should be carefully evaluated before widespread implementation