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Lower Copayments and Use of Mail-Order Pharmacy may Reduce Disparities in Adherence to Blood-Pressure Medication

December 10, 2012



OAKLAND, Calif. — New research suggests that making prescription refills more affordable and easier to get may reduce disparities among hypertension patients.

Kaiser Permanente Division of Research

An analysis of more than 44,000 patients recently diagnosed with high blood pressure in Kaiser Permanente Northern California identified important differences in medicine-taking behaviors among racial and ethnic groups. Lower copayments and the use of mail-order pharmacy increased refills of blood-pressure medicine, and these factors were associated with reduced disparities.

Kaiser Permanente scientists published the retrospective study on adherence to medications prescribed for high blood pressure, also known as hypertension, in the Dec. 10 online edition of Archives of Internal Medicine.

“The differences that we found occur early on, after a patient has been diagnosed with hypertension,” explained Alyce S. Adams, PhD, research scientist with the Kaiser Permanente Division of Research and lead author of the study. “In fact, as early as the first refill, some patients are forgoing their hypertension medication.”

Hypertension is a major risk factor for heart disease, and even modest reductions in blood pressure are associated with significant reductions in heart attacks, strokes and deaths related to cardiovascular disease. Its impact is devastating to communities of color, particularly among blacks, where males have the highest hypertension death rates of any other racial, ethnic or gender group. This is attributable in part to significantly lower control rates as compared to whites, according to a 2010 report from the U.S. Centers for Disease Control and Prevention.

According to the CDC, only about 54 percent of people diagnosed with hypertension nationally have it under control. Kaiser Permanente Northern California has become a national model for hypertension control, with about 87 percent of its members controlling their blood pressure and experiencing concurrent dramatic reductions in strokes and heart attacks.

“This research points to specific strategies that have the potential to reduce disparities in blood pressure by easing access to important medications,” Adams said.“Our findings suggest that while racial and ethnic differences in medication adherence persist — even in settings with high-quality care — interventions such as targeted copay reductions and mail-order pharmacy incentives have the potential to reduce these disparities.”

Using Kaiser Permanente Northern California’s integrated electronic health record system, the researchers identified 44,167 patients who had been prescribed antihypertensive medications for the first time in 2008. Because more than 95 percent of Kaiser Permanente patients obtain prescriptions from the health plan’s in-house pharmacy, the researchers were able to monitor when, whether and how these patients refilled their hypertension medications.

Primary nonadherence, or failing to pick up a prescribed medication, was rare. More than one-third of patients failed to refill a medication within 90 days of the first fill (called “early nonpersistence”), and this varied considerably by race. After adjusting for other variables, black (43.6 percent), Asian (38.8 percent) and Latino (41.6 percent) patients all had significantly higher odds of early nonpersistence than white (31 percent) patients.

Nonadherent patients were defined as those with gaps in medication refills for more than 20 percent of the days in the measurement period, or having medication available less than 80 percent of the time. Of the nonadherent patients studied, 28 percent were black, 26.9 percent were Latino, 20.3 percent were Asian, and 16.7 percent were white. The impact of race and ethnicity on nonadherence was significantly reduced when the authors accounted for differences in copayment and enrollment in mail-order pharmacy; both mail-order pharmacy enrollment and lower copayments were significantly associated with a lower likelihood of being nonadherent.

Co-authors of the study were Connie Uratsu, RN, Wendy Dyer and Julie A. Schmittdiel, PhD, of the Kaiser Permanente Division of Research (Oakland, Calif.); David Magid, MD, MPH, Arne Beck, PhD, and Michael Ho, MD, PhD, Institute for Health Research, Kaiser Permanente, Denver; Patrick O’Connor, MD, MPH, HealthPartners Research Foundation, Minneapolis; and Melissa Butler, PharmD, MPH, PhD, Kaiser Permanente Center for Health Research Southeast, Atlanta.

The National Heart, Lung and Blood Institute and the National Institute for Mental Health funded the study, as a supplement to the Health Maintenance Organization Research Network Cardiovascular Disease Network. The National Institute for Diabetes and Digestive and Kidney Diseases provided additional support to co-authors Adams, Dr. O’Connor and Schmittdiel.

Archives of Internal Medicine is published by the American Medical Association.


About Kaiser Permanente

About Kaiser Permanente Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve 8.6 million members in nine states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: www.kp.org/newscenter.


About the Kaiser Permanente Division of Research

About the Kaiser Permanente Division of Research The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, the center's 400-plus staff is working on more than 250 epidemiological and health services research projects. About Kaiser Permanente Research Kaiser Permanente's eight research centers comprise one of the largest research programs in the U.S. and engage in work designed to improve the health of individuals everywhere. KP HealthConnect™, Kaiser Permanente's electronic health record, and other resources provide population data for research, and in turn, research findings are fed into KP HealthConnect to arm physicians with research and clinical data. Kaiser Permanente's research program works with national and local health agencies and community organizations to share and widely disseminate its research data. Kaiser Permanente's research program is funded in part by Kaiser Permanente's Community Benefit division, which in 2007 directed more than $1 billion in health services, technology, and funding toward total community health. About Kaiser Permanente Kaiser Permanente is America's leading integrated health plan. Founded in 1945, the program is headquartered in Oakland, Calif. Kaiser Permanente serves 8.7 million members in nine states and the District of Columbia. Today it encompasses Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals and their subsidiaries, and the Permanente Medical Groups. Nationwide, Kaiser Permanente includes approximately 159,000 technical, administrative and clerical employees and caregivers, and 14,000 physicians representing all specialties. The organization’s Labor Management Partnership is the largest health care partnership in the United States. It governs how more than 130,000 workers, managers, physicians and dentists work together to make Kaiser Permanente the best place to receive care, and the best place to work. For more Kaiser Permanente news, visit the KP News Center at: http://xnet.kp.org/newscenter