To ensure that a new asthma prescription could be identified, the patient had to be in the Geisinger Clinic system for at least 1 year before the prescription date.Įligible medications fell into the following subclasses: sympathomimetics, oral corticosteroids, inhaled corticosteroids, leukotriene modulators, bronchodilators, or a combination of these classes. In this study we included patients who were 18 or older at the time of a new asthma prescription had sought care from the Geisinger Clinic had GHP pharmacy benefit and were prescribed a medication to treat asthma between January 2002 and September 2006 that had not been prescribed or filled within the previous 6 months. The Geisinger Clinic patient population includes residents from central and northeastern Pennsylvania, a predominantly white population. Initially started as a group practice HMO, GHP has expanded into a network model and now has more than 220,000 members. Although GHP shares its name with Geisinger Clinic, it is an independent entity and one of the nation's largest rural health maintenance organizations (HMOs). GHP is one part of Geisinger's diverse payer mix and accounts for 30% of the Geisinger Clinic's patient volume. An EHR system was installed in all Geisinger Clinic community practice sites and specialty clinics, allowing for the integration of clinical information across diverse settings of care and making all patient information available in digital form. The Geisinger Clinic is a multispecialty practice with more than 40 clinic sites and more than 600 providers. In the case of first-fill of asthma medications, reliable linking of EHR to claims data within a single healthcare system helps address recall bias (prescriptions and fills are accurately recorded), selection bias (all patients with a new asthma prescription are included), and statistical power (the data sets comprise thousands of patients). Our primary data sources were 2 large, linked data sets: Geisinger Clinic's EHR and GHP's claims database. We used a retrospective cohort design to assess the proportion of patients who filled a first-time prescription for an asthma medication and then examined characteristics associated with first-fill. Through these linked databases we identified prescriptions that were written but ultimately not filled by patients. To test these hypotheses, we linked prescribing information from Geisinger Clinic electronic health records (EHRs) to pharmacy claims data of one insurer, Geisinger Health Plan (GHP). We hypothesized that the following “dimensions of adherence” 4 are associated with failure to fill a prescription, patient-related (ie, higher comorbidity index, more office visits, and greater pill burden, as well as age by means of comorbidity and loss of function) condition- and treatment-related (ie, number of asthma medications, inhaled versus oral route of delivery, and controller versus reliever medication) and healthcare system–related (ie, higher copay).
10– 12 The present study seeks to add to that understanding. Although the literature on adherence is expansive, understanding first-filling of prescriptions for asthma medication is still in its preliminary stages. In addition, if prescription no-fill is not recognized as a possible cause for treatment failure, a second-line medication could be unnecessarily prescribed, exposing the patient to additional costs and potential side effects. An accurate estimate of adherence and treatment effects depends on prescription filling, after which other metrics of adherence (ie, medication taking) can be considered. 9įirst-fill-patient's filling of a new prescription-is essential to adherence.
Much of the adherence literature to date has focused on whether the patient takes the medication as prescribed (assuming that the prescription has been filled) and relies on patient self-reporting, which is unreliable. 8 Understanding and improving patient adherence is one way to improve asthma care. 3 In addition, adherence among the patient population is low, with adherence to inhaled corticosteroids among the lowest in all patients with chronic conditions. Medication nonadherence among patients with asthma is associated with increased emergency department visits and hospitalizations. 5– 7Īdherence in asthma is particularly important. 4 Although the adherence literature is extensive, previous studies have used disparate methods, patient populations, and definitions, making it difficult to determine which of these factors is most significant.
2, 3 The World Health Organization classifies adherence-related factors into 5 dimensions: healthcare-related, socioeconomic, disease-related, therapy-related, and patient-related. But “low adherence is ubiquitous and undermines treatment benefits.” 1 Patients with chronic conditions in developed countries take about only half of their medications. Adherence to prescribed medications is necessary to improve outcomes.
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