Poor adherence with prescription medications is ubiquitous and costly. Physicians'assessments of patients'adherence are inaccurate, which makes it attractive to use pharmacy claims to identify nonadherence. But research clearly shows that simply giving physicians claims data about nonadherence is ineffective, probably because it is not clear what action to take, and because the cost in time and energy of any taking action is great. What is currently lacking is a practical way to effectively integrate diagnostic information and treatment expertise into work flows in primary care physicians'offices, and an effective method of inducing physicians to act on it. The long term goal of this research is to develop systems that effectively connect pharmacy benefits managers (PBMs), primary care doctors, clinical pharmacists, and patients in ways that improve medication adherence and patients'health outcomes. The overall objective of this application, which is the next step toward attainment of our long term goal, is to conduct a pilot test of an intervention that delivers timely diagnostic information about nonadherence to physicians, and then compares the effectiveness of two ways to provide pharmacist services to primary care physicians and their patients. Taking advantage of the principle of intelligent choice architecture, in one arm the pharmacist will contact the patient as the default option (with no action required by the doctor), and in the other the pharmacist will contact the patient only if the doctor actively chooses that the pharmacist take action. Our central hypothesis, which is strongly supported by work in other fields, is that the pharmacist will be consulted more often when intervention by the pharmacist is the default outcome, and that the default pharmacist intervention will be the most beneficial for adherence outcomes. The rationale for choosing this approach is the observation, from behavioral economics, that even small costs in the short term can prevent physicians from pursuing a course of action that has important long term benefits. The proposed research is relevant to the NIH's mission because poor adherence with medications for chronic conditions like HIV is a serious, worldwide problem. This RC4 proposal has three Specific Aims: 1) Establish and test the technical and communications infrastructure required for the conduct of this clinical trial, 2) Conduct and evaluate a clinical trial of an intervention comparing methods of offering pharmacist services to primary care physicians, and 3) Evaluate economic outcomes. This proposal is significant because medication nonadherence is a common and costly problem for which there are currently few effective solutions. It is innovative because it applies principles from behavioral economics to the problem of medication adherence;because it tests a communications architecture that links PBMs, physicians, patients, and pharmacists;because it will take place in a loose alliance of small group practices;and because it includes analysis of economic outcomes. While this pilot study focuses on diabetes, hypertension, and hyperlipidemia, the intervention itself is broad and cross-cutting, and applicable to any medical condition and all care settings.

Public Health Relevance

While achieving optimal health outcomes for persons with chronic medical conditions requires that patients adhere to effective medications, few simple and effective methods to accomplish this have been developed. This proposed pilot study develops an innovative communications infrastructure that links pharmacy benefits managers, physicians, patients, and pharmacists, and uses principles from behavioral economics to compare the effectiveness of two different ways to use this infrastructure. While this pilot study focuses on diabetes, hypertension, and hyperlipidemia, the intervention is applicable to any medical condition and all care settings.

National Institute of Health (NIH)
National Institute on Aging (NIA)
High Impact Research and Research Infrastructure Programs—Multi-Yr Funding (RC4)
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Special Emphasis Panel (ZAG1-ZIJ-3 (A2))
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King, Jonathan W
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Brown University
Public Health & Prev Medicine
Schools of Public Health
United States
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