What makes it more likely for new prescriptions to be filled?

Recently, some colleagues and I at NYU looked at factors influencing first-fill adherence to new asthma prescriptions. Lower copay and oral administration were associated with greater first fill. See the abstract below and the full paper here.

Lower Copay and Oral Administration: Predictors of First-Fill Adherence to New Asthma Prescriptions

Background: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.

Objective: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.

Methods: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.

Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).

Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed through simple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

Studying with Big Pharma

The American Board of Internal Medicine ratifies a core of medical knowledge in which the qualified internist is supposed to demonstrate proficiency. I am using MKSAP to study - it's a series of study guides produced by the American College of Physicians. Before the table of contents, the contributors are listed, together with their disclosed involvement with (meaning: compensation by) pharmaceutical companies.

It'd be asking too much to eliminate pharm-phunded contributors from ostensibly nonpartisan guides which reflect the best available consensus of our profession (that would be...legitimate!). Nor do I think it's likely that their contributions will be vetted by a pharm-free referee (that would be...adequate!). In the absence of these strategies, it would be nice - paradoxically - if those medications mentioned in the text could be listed on first appearance by brand name and manufacturer. Otherwise how are we to know which contributor is putting a golden shine on the clinical evidence?