It improves with age Adherence Like Why is Patient VP Analytical - PDF document

October 15, 2009 It improves with age Adherence Like Why is Patient VP Analytical Paul Wilson Services Wine?

Why is Adherence Important? Medication non-adherence estimated to lead to over $177 Billion in unnecessary health care costs in the US Hospital admissions $121.5B Long Term care admissions $32.8B Doctor visits/other $22.7B (Ernst and Grizzle, J Amer Pharmaceutical Assoc 41(2), 2001) “Drugs don’t work in patients who don’t take them” –C. Everett Koop, M.D.

Factors Influencing the 1 st Fill Physician Physician FIRST FILL Patient Pharmacy DTC Pharmacy DTC Managed Care Managed Care Copay Tier

Factors Influencing the Continuing Fills Social Support Networks CONTINUING FILLS Groups Internet Demographics Physician Physician FIRST FILL Patient Refill Pharmacy DTC Pharmacy DTC Reminders Managed Care Managed Care Comorbidities Media Coverage Copay Tier

Moderate wine consumption, like patient adherence, is good for your health Studies show: • Wine consumption raises HDL cholesterol levels and reduces plaque formation 1 • Wine prevents blood clotting 2 • Moderate red wine consumption reduces risk of colon cancer by 45% 3 • Moderate drinking slows brain decline 4 • Anti-oxidants in white wine improve lung functioning 5 • Wine strengthens your bones 6 4 Columbia University NeuroEpidemiology 2006 1 International Journal Molecular Medicine 2005 2 Columbia University study, Stroke 2006 5 University of Buffalo study, Amer Thoracic Society 2002 3 Amer Journal GastroEntology, 2005 6 St Thomas Hospital, London study 2004

Patient Adherence?

Factors Influencing the Patient Behavior Social Support Networks Groups CONTINUING FILLS Internet Demographics Physician Physician FIRST FILL Refill Patient Pharmacy DTC Pharmacy DTC Reminders Managed Care Managed Care Comorbidities Media Coverage Copay Tier

Pharmacy’s Potential to Improve Adherence Reasons patients don’t take their Percent prescriptions as instructed 20% Affordability of medication 20% Patient feels they do not need medication 17% Side effects of medication 16% Forgetfulness 5% Lack of concern for their condition 5% Lack of information on disease 5% Lack of information of Rx prescribed 5% Lack of family/social support 3% Low satisfaction with Rx prescribed 2% Poor relationship w/ pharmacist or physician 2% Patient Received Prior recommendation against the drug Source: AstraZeneca Physician Survey October 2008

Adherence Comparison: Medical Possession Ratio Differences in adherence become apparent when looking at MPRs: Pharmacies outperform Food Stores in all four therapeutic categories MPR: # of days’ supply during the analysis period / number of days during the analysis period. Cohort includes all patients filling during August 2008, analysis period is 365 days. Source: Catalina Health Resource

Persistence in Food Stores vs. Pharmacies Persistence in Type-2 Diabetes is better in Pharmacies than in Food Stores Data are for the type 2 diabetes market, but similar results were seen in other chronic therapeutic areas Source: Catalina Health Resource

Persistence by Days’ Supply: Lipid Lowering Drug Observation: Patients with 90-days’ supply are more persistent than those with 30-days’ supply Percent of patients persistent as of fill x with a 30-day grace period Source: Catalina Health Resource

Persistence by Days’ Supply: Generic Lipid Lowering Drug Percent of patients persistent as of fill x with a 30-day grace period Source: Catalina Health Resource

Factors Influencing the Patient Behavior Social Support Networks Groups CONTINUING FILLS Internet Demographics Physician Physician FIRST FILL Refill Patient Pharmacy DTC Pharmacy DTC Reminders Managed Care Managed Care Comorbidities Media Coverage Copay Tier

Managed Care’s Potential to Improve Adherence Reasons patients don’t take their Percent prescriptions as instructed 20% Affordability of medication 20% Patient feels they do not need medication 17% Side effects of medication 16% Forgetfulness 5% Lack of concern for their condition 5% Lack of information on disease 5% Lack of information of Rx prescribed 5% Lack of family/social support 3% Low satisfaction with Rx prescribed 2% Poor relationship w/ pharmacist or physician 2% Patient Received Prior recommendation against the drug Source: AstraZeneca Physician Survey October 2008

Adherence Comparison: Methods of Payment Cash Medicaid Medicare Part D Third Party Brand Generic Brand Generic Brand Generic Brand Generic Patient Count 23,967 40,370 26,972 29,227 204,490 289,542 962,208 1,210,974 Avg Rx per Patient 4.3 5.2 7.2 7.7 7.4 7.8 7.3 7.2 Avg Pills per Patient 156.7 207.1 236.0 248.6 261.4 283.1 242.7 253.1 Compliance Rate 78.2% 82.6% 81.8% 81.2% 85.5% 86.5% 83.9% 84.3% Medical Possession 42.8% 54.7% 63.7% 66.1% 70.8% 74.9% 66.8% 68.0% Ratio Days Late 23.8 17.2 13.3 13.7 11.2 10.2 11.6 11.7 Patient cohort: all patients filling Brand x and Generic y during August 2008. Analysis period is one year. Source: Catalina Health Resource

Persistence by Payment Method Patient cohort: all patients filling Brand x and Generic y during August 2008. Analysis period is one year. Grace period is 30 days. Source: Catalina Health Resource

Copays have kept rising Average Rx copayment by cost sharing tier (2000-2008) Drug cost sharing classification Note: Among covered workers. Years shown (9) are 2000 through 2008.Source: Kaiser Family Foundation (Employer Health Benefits 2008).

Copays affect patient behavior Change in days supplied after doubling copay (2004) Drug category Source: Goldman et al., JAMA (2004); 291: 2344-2350.

Growth of copays is being off-set by rebate and coupon programs Opinion of Health-Related Coupons Received with Prescriptions Source: G&S Research Note: Values <5% are not displayed in chart. How much would you say you like or dislike receiving these coupons for products related to your health when you pick up your prescriptions? (Of the 16% of patients who received coupons, n=805)

Factors Influencing the Patient Behavior Social Support Networks Groups CONTINUING FILLS Internet Demographics Physician Physician FIRST FILL Refill Patient Pharmacy DTC Pharmacy DTC Reminders Managed Care Managed Care Comorbidities Media Coverage Copay Tier

Like wine, adherence improves with age All metrics are for the Cholesterol Market, but similar results were seen for the other chronic therapeutic categories. Source: Catalina Health Resource

Adherence Comparison: Gender Surprise! Women are less adherent than men in both Food Stores and in Pharmacies, both genders visit both store types equally Compliance MPR Days Late Total Rate Days of Therapy Food Stores Gender Men Women Men 89.9% 72.7% 8.3 238.6 Food Stores 19.3% 19.6% Women 88.2% 70.2% 9.7 235.7 Pharmacies 80.7% 80.4% Pharmacies Men 89.7% 78.2% 8.1 280.1 Women 88.0% 75.8% 9.5 276.8 All metrics are for the Type 2 Diabetes market, but similar results were seen for the other chronic therapeutic categories. Source: Catalina Health Resource

Adherence Segmentation Analysis Patient Selection Period Transaction period 120 days (August 07 – October 07) 52 weeks (November 07 – October 08) • Hypertension • Diabetes • Severe Rheumatoid • Arthritis Hypertension • High Cholesterol Adherence • Congestive Heart Failure Behavior • Cancer • Osteoporosis • Depression • Obesity • Post Myocardial Infarction • Menopause / Post Menopause

Hypertension Patient Adherence Tree All Hypertension Brand X Patients Base=104,751 (100%) % ADH=64.1 Patients without Congestive Patients with Congestive Heart Heart Failure Failure N = 97,918 (93%) N = 6,833 (7%) % ADH = 63.0 % ADH = 80.0 Patients with Low Patients with Medium Patients with High Income (le42.5K) Income (42.5-69.6K) Income (GE 69.6K) N = 1,570 (2%) N = 3,584 (3%) N = 1,570 (2%) % ADH = 77.7 % ADH = 79.7 % ADH = 83.3 Patients Aged LE49 Patients Aged GE65 Patients Aged 50-64 N = 12,463 (12%) N = 33,330 (32%) N = 52,125 (49%) % ADH = 56.6 % ADH = 66.8 % ADH = 59.6 BRANCH # 1 BRANCH # 2 BRANCH # 3 % ADH = patients with MPR >=70% Source: Catalina Health Resource

Hypertension Patient Adherence Tree: Branch 2 BRANCH # 2 Patients without CHF and with Age 50-64 N = 33,361 (32%) % ADH = 59.6 Patients without Diabetes Patients with Diabetes N = 17,917 (17%) N = 15,444 (15%) % ADH = 56.6 % ADH = 63.1 Patients with Poor Patients with Patients with Good Patients without Patients taking Beta HT Control Medium HT HT Control BetaBlockers Blockers N = 5,336 (5%) N = 5,758 (6%) Control N = 9,111 (9%) N = 8806 (8%) % ADH = 66.3 % ADH = 59.9 N = 4,350 (4%) % ADH = 53.3 % ADH = 60.1 % ADH = 63.3 % ADH = patients with MPR >=70% Source: Catalina Health Resource

Increased Adherence: New vs. Experienced Patients New Patients typically respond better to adherence programs , however, they generally only represent 30-40% of the patient population Source: Catalina Health Resource