Patient acceptability of and readiness-to-pay for pharmacy-based health membership plans to improve hypertension outcomes in Lima, Peru

Abstract

Introduction:

Pharmacies have been used to improve population health in Peru and other countries globally, operating as a non-traditional health access point. A pharmacy-based model holds potential to improve patient management of hypertension, a leading risk factor for non-communicable diseases in low- and middle-income countries. The aim of this study was to evaluate patient acceptability of hypertension services and health membership plans, if offered through private pharmacies in the future.

Methods:

A cross-sectional study was conducted with 347 hypertensive individuals who purchased anti-hypertensive medications in a private pharmacy during the study period (July–October 2012). The study included a brief survey assessing patients’ acceptability of and readiness-to-pay for pharmacy-based hypertension management services. Chi-square tests for differences in proportions were used to evaluate whether any demographic characteristics (e.g., binary variables for age, time since diagnosis, and type of medication usually purchased) could identify groups of hypertensive individuals that might be more or less likely to use pharmacy-based services. Multiple logistic regression was used to estimate associations between readiness-to-pay for pharmacy-based health membership plans and patient-level characteristics.

Results:

Over 80% of individuals indicated they would be interested in pharmacy-based hypertension services, particularly discounts on anti-hypertensive medications and free blood pressure screenings. Compared to individuals 65 years of age or older, individuals under 65 years were more interested in receiving at least one pharmacy-based service. Another 80% indicated they would be interested in purchasing a monthly health plan through a pharmacy that provided access to hypertension services each month. The vast majority of individuals interested in pharmacy-based services indicated they would pay ≤$3.69 US/month to participate in a monthly health membership plan.

Conclusions:

Hypertensive patients would be interested in using and ready to pay for pharmacy-based hypertension services.

Introduction

Non-communicable diseases and their risk factors, such as hypertension, are of growing concern for low- and middle-income countries (LMICs) due to increasing prevalence; yet resources available to invest in comprehensive prevention and treatment strategies remain limited.¹ In addition to impacting health, the proliferation of chronic diseases in LMICs may also contribute to an ongoing cycle of poverty and undermine the economic development of these nations.^2,3

Globally, hypertension is the leading risk factor for morbidity and mortality, accounting for 9.4 million deaths and 7% of the global disease burden in 2010.⁴ Like other chronic conditions, hypertension disproportionately afflicts individuals in LMICs with nearly three-quarters of the world’s hypertensive population estimated to be in developing countries by 2025.⁵ In Peru, hypertension affects 12–30% of the population, depending on regional and population-based characteristics.^6–9 Despite growing numbers, only 40% of people diagnosed with hypertension receive treatment, and even fewer achieve adequate control (i.e., systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg, per recommendations by the Joint National Committee).^7,10 A recent systematic review of prevalence, awareness, treatment and control of hypertension demonstrated a similar trend across LMICs globally, highlighting the need for more effective prevention and treatment programs in Peru and other LMICs.¹¹

Given the complexities of diagnosing and treating hypertension and variations in prevalence across populations, innovative and multi-dimensional efforts are needed to address hypertension on a public health level.¹² In several LMICs–such as Thailand, Brazil and Paraguay–where access to the formal health system can be challenging and cost-prohibitive for patients, private pharmacies have been leveraged to improve hypertension prevention and management.^13–18 Leveraging private pharmacies for public health interventions has previously improved prevention and management of sexually transmitted infections in Peru.^19,20

Pharmacies and boticas are ubiquitous in Peru, with more than 10,000 establishments across the country, the majority from six major chains of accredited pharmacies (“private pharmacies”).²¹ Private pharmacies are required to have a licensed pharmacist on staff at all times, whereas a botica is not. In contrast to public pharmacies (which work inside Ministry of Health establishments), private pharmacies are often more accessible in terms of proximity, availability of hours, and wait times. Several pharmacies also have miniclinics and larger clinical offices (polyclinics) associated with their pharmacy store that provides primary care, laboratory, and urgent care services for a fee to patients, but they are not well linked and no referrals are done from pharmacies to clinics. In locations with clinical and pharmacy associations, the pharmacy and clinical offices are often geographically adjacent to one another.

To date, however, comprehensive pharmacy-based hypertension management programs have not been implemented in private pharmacies in Peru or in any other Latin American country. Some pharmacies provide blood pressure screening and some have begun collaborations with the Peruvian Ministry of Health for publicly insured patients²²; yet, these efforts are not yet well established and do not support individuals without public insurance.

Even as Peru works toward universal health care coverage, only 60–65% of individuals have health insurance.²³ Primary care services provided through private pharmacies might offer affordable access to health care services for patients, such as monthly check-ups and blood pressure screenings. If patients use such services, pharmacy-based programs could fill the gap for the nearly 40% of individuals without insurance.

A key correlate of success for hypertension prevention, management, and medication adherence is patient-centered care and treatment follow-up.^14,24 A recent study in a Canadian population also found patient loyalty to a specific community pharmacy to be associated with improved medication persistence for diabetes.²⁵ As such, offering patient-focused care through pharmacy-based programs that create an ongoing relationship between patients and their pharmacy of choice could aid in the improved identification and long-term management of hypertension. In order to incentivize continuity of pharmacy-based care, pharmacies might consider offering monthly health membership plans that provide patients with services for hypertension for a nominal fee. Inclusion of a small fee may incentivize patients to regularly use services if they felt such services provided good value for money. In turn, this may generate revenues that would incentivize private pharmacies as for-profit entities to provide services of value to hypertensive patients, while creating a positive public health impact.

This innovative approach to hypertension management would leverage the resources of private institutions to improve public health; however, success would largely depend on patient acceptability and uptake. This study investigated the potential for private pharmacies in Lima, Peru to launch health membership programs by assessing perspectives of patients diagnosed with hypertension who purchased anti-hypertensive medications in pharmacies. Specifically, the study investigated the acceptability of providing patients with pharmacy-based services and pharmacy-based health membership plans for hypertension, including access to outpatient and urgent care consultations, discounted medications, free blood pressure screenings, and laboratory tests for comorbidities and interpretation of test results.

Materials & methods

Study design

A cross-sectional study was designed to assess the acceptability and readiness-to-pay for pharmacy-based hypertension services using structured, anonymous questionnaires with patients who entered the pharmacy to purchase anti-hypertensive medications.

Patients and eligibility criteria

Surveys were conducted with potential users of the proposed health membership plans in five pharmacy locations of a private pharmacy in Lima, Peru. The five study locations included stores in middle- to low-income urban zones of Cercado, Magdalena and Chorrillos, selected based on an analysis of the highest frequency of anti-hypertensive medication sales across the pharmacy’s store locations in the metropolitan area of Lima and socioeconomic status (i.e., focus on districts with socioeconomic levels of C and D). This pharmacy has the potential capacity to provide health membership plans for hypertension based on its current business model, which includes: pharmaceutical dispensation, laboratory services, insurance, domestic products (e.g., shampoo), and medical care through clinics (“medicentros”) affiliated with some pharmacy store locations.

The sample size was determined a priori based on an average prevalence of hypertension in Peru (27.3%),²⁶ a confidence level of 95%, and 5% sampling error. This provided the low-end sample size of 305 participants. To be included in the study, individuals needed to be 18 years of age or older, have a medical diagnosis of hypertension, and purchase anti-hypertensive medications in one of the pharmacy store locations participating in the study. Pregnant women were excluded from participation. The Institutional Review Board at the Universidad Peruana Cayetano Heredia in Lima, Peru provided ethical approval for the study. The Institutional Review Board provided a waiver of written consent to ensure total anonymity of survey participants. Individuals who chose to participate were provided information about the study and their rights as a study participant.

Study instrument

Development of health membership plan components

To evaluate the acceptability of pharmacy-based health membership plans for hypertension management, two hypothetical health plans (“basic” and “premium”) were developed that could be offered to hypertensive individuals through a private pharmacy (Table 1). Development of the hypothetical plan components was informed by a literature review of hypertension management and informal interviews with experts in the fields of community pharmacy, chronic disease, and pharmacy administration.^13,27 Ongoing discussions were held between pharmacy administrators, affiliated health clinics and the study team to understand the workflow of the pharmacy and feasibility of the proposed services. The health plans were designed to fit into the current workflow of the pharmacy (Table 1).

Table 1.

Proposed hypertension management packages for pharmacy clients

Proposed health plan characteristics	Basic plan includes	Premium plan includes
Urgent care visits	One visit per month	Two visits per month
Blood pressure measurement in pharmacy	One measurement every 15 days	One measurement every 15 days
Discounts on anti-hypertensive medications	Amount determined by pharmacy	Amount determined by pharmacy
Medical consultations with doctor at mini-clinic at pharmacy	Not included	Once per month
Lab tests + interpretation of results: (glucose, cholesterol and triglycerides)	Not included	Once every 6 months

Plan components included: 1) urgent care visits with doctors and nurses on staff at poly- and miniclinics adjoining some pharmacy locations to support individuals who experience adverse events, such as severe headache, chest pain or symptoms concerning for stroke; 2) bi-monthly blood pressure measurements by trained staff (pharmacist or pharmacy technician) in the pharmacy to help patients monitor and control their disease; 3) discounts on anti-hypertensive medications (e.g., a percentage or fixed-cost reduction); 4) medical consultations with a clinician at clinics adjoining some pharmacy locations or through a telephone service; and 5) laboratory tests for comorbidities and interpretation of results. The premium health plan would offer access to all of these services, while the basic health plan would offer access only to urgent care visits, blood pressure screening and medication discounts. By subscribing to a monthly health membership plan, patients would not be required to pay for these services at the time of use. Costs would be covered by the pharmacy, offset by monthly subscriber payments. To ensure patient safety and program success, it would be important for staff at the private pharmacy (pharmacists and pharmacy technicians) and affiliated health clinics to receive training in hypertension prevention, detection, and management (e.g., blood pressure screening, equipment calibration, referrals to clinicians, etc.).²⁸ However, training and capacity building were beyond the scope of this acceptability study.

Patient acceptability survey design

To determine whether hypertensive individuals were interested in using pharmacy-based services for hypertension management, a structured questionnaire was developed and used to survey a cross-sectional sample of patients who purchased anti-hypertensive medications in the pharmacy setting. The survey included close-ended, multiple choice questions to assess patient demographics (age, diagnosis status, time since hypertension diagnosis), types of medications purchased (e.g., generic or brand name), pharmacy location, frequency of visits to the doctor related to hypertension, monthly amount spent on medications and medical visits for hypertension, acceptability of and readiness-to-pay for potential pharmacy-based hypertension services. The survey asked participants about their interest in receiving each type of service indicated in the health plans. Respondents were allowed to select as many of the proposed pharmacy-based health services as they were interested in. Participants were also asked to rank the services in order to identify which were most important to the majority of patients.

Prior to administering the survey, the instrument was piloted with a small number (<5) of hypertensive individuals in the pharmacy to ensure questions were asked in a manner that patients understood and to allow us to refine the survey instrument as needed. These data were not included in the analysis.

Data collection

Individuals were referred to the study team by pharmacists as they purchased an anti-hypertensive medication in the pharmacy. Research investigators then explained the study objective and invited individuals to participate in the anonymous survey. Individuals who agreed to participate were provided an information sheet about the study and their rights as research participants. Research investigators administered surveys to patients, recorded responses onto paper survey forms, and retained them for data entry purposes. Each survey lasted approximately 5 minutes.

Statistical analysis

Descriptive statistics were used to analyze demographics and acceptability of pharmacy-based hypertension services and monthly health plans. Potential demand for services and health membership plans were analyzed stratified by age, time since diagnosis, and type of medications usually purchased (generic only or brand name/brand name + generic) as factors that could influence uptake, determined a priori. Chi-square tests for differences in proportions were used to evaluate whether interest in pharmacy-based services differed significantly between binary categories of demographic characteristics (e.g., <65 years vs. ≥65 years, longer vs. shorter history of diagnosis, and whether individuals purchase generic vs. brand-name + generic).

To assess monthly amounts of money spent on care related to hypertension and readiness-to-pay for health membership plans, categorical survey variables were created with expenditure range options in the Peruvian currency of Nuevos Soles (≤S/. 10, S/. 11-30, S/. 31-60, S/. >60; ≤$3.69 US, $3.70–$11.05 US, $11.06–$22.12 US, > $22.12 US). All monetary amounts are reported here in 2015 U.S. Dollars, using a World Bank Official Exchange Rate and Consumer Price Indices to convert from 2012 Peruvian Nuevos Soles.²⁹ Finally, multiple logistic regression analyses were used to investigate possible associations between readiness-to-pay for pharmacy-based health membership plans and the pre-specified patient-level characteristics. A binary variable for readiness-to-pay was used as the dependent variable, defined as whether individuals indicated they would purchase either health plan offered during the survey process. Patient-level characteristics were used as the independent variables. Model goodness of fit was assessed using a Hosmer–Lemeshow test, which indicated that the pre-specified model fit the data well (P = 0.4133).

Approximately 9% of respondents had missing data for the variable assessing type of medication usually purchased (generic, brand name, or both). Logistic regression and Wald test analyses detected no statistically significant differences between the group of participants with and without missing data, and thus, the analysis was conducted including only the available data. All statistical analyses were conducted using Stata (Release 13. College Station, TX: StataCorp LP).

Results

Survey respondent characteristics

In total, 347 individuals with a diagnosis of hypertension completed the survey (Table 2). Respondents had a mean age of 63 years (range: 39–91 years). Approximately, 58% of individuals were diagnosed in the 10 years prior to the survey, while 40% had a diagnostic history of more than 10 years. All patients were taking an anti-hypertensive medication. Approximately, 65% reported they only purchased generic anti-hypertensive medications, while the remaining 35% purchased brand name only or brand-name + generics. The most commonly reported anti-hypertensive medications used were Enalapril (43%) and Losartan (30%). Nearly two-thirds (64%) of respondents reported visiting a doctor on a monthly basis to check blood pressure. Most patients reported monthly expenditures for hypertension-related medications and medical visits to be ≤$3.69 US (53% of patients); however, 24% reported spending more than $11.05 US per month.

Table 2.

Characteristics of clients participating in acceptability and readiness-to-pay survey

Patient characteristics (N = 347)	Value
Age (mean, range)	62.6 (38–91)
Time since hypertension diagnosis (N, %)
<5 years	(128/347) 36.9%
5–10 years	(74/347) 21.3%
>10 years	(140/347) 40.4%
Don’t know	(5/347) 1.4%
Of those regularly taking medications, type of medication usually purchased for blood pressure (N, %)
Generic only	(207/318) 65.1%
Brand name and/or both brand name + generics	(111/318) 34.9%
Specific medication taken to control high blood pressure (N, %)a
Atenolol	(48/318) 13.5%
Candesartan	(20/318) 6.3%
Captopril	(48/318) 15.1%
Enalapril	(135/318) 42.5%
Losartan	(94/318) 29.6%
Hydrochlorozide	(27/318) 8.5%
Telmisartán	(3/318) 0.9%
Other	(89/318) 28.0%
Frequency of visits to doctor to check blood pressure (N, %)
Once per month	(221/347) 63.7%
Once every three months	(99/347) 28.5%
Once every six months	(10/347) 2.9%
Once per year	(9/347) 2.6%
No response	(8/347) 2.3%
Average amount spent on medicines and medical visits for hypertension each month (N, %)b
≤$3.69 US	(182/347) 52.5%
$3.70–$11.05 US	(81/347) 23.3%
$11.06–$22.12 US	(41/347) 11.8%
<$22.12 US	(41/347) 11.8%
No response	(2/347) 0.6%

^aDoes not total 100% since some patients indicated taking more than one medication.

^b2012 Peruvian Nuevos Soles converted to 2015 U.S. Dollars using World Bank Official Exchange Rate and Consumer Price Indices. Survey originally asked clients ranges of Nuevos Soles (≤10 N. Soles, 11–30 N. Soles, 31–60 N. Soles, <60 Nuevos Soles).

Interest in pharmacy-based health membership plans for hypertension management

The majority of patients (81%) reported they would be interested in receiving at least one service in the pharmacy to monitor and control their hypertension (Fig. 1). Further, most patients were interested in more than one pharmacy-based service, with 80% interested in receiving discounts on medications, 66% interested in receiving blood pressure measurements, 66% interested in regular health check-ups, 55% interested in laboratory tests and analyses, and 25% interested in urgent care consultations in the pharmacy.

Fig. 1.

Pharmacy-based hypertension management services ranked most desirable by respondent characteristics.

Among those interested in receiving pharmacy-based services, 39% ranked discounts on medications as the service of greatest interest, followed by free blood pressure screenings (18%), the ability to receive regular health check-ups with a health care provider (15%), lab tests and analysis (8%), and access to urgent care visits (2%) (Fig. 1). A chi-square test for differences in proportions showed that individuals <65 years old were significantly more interested pharmacy-based hypertension services compared to those ≥65 years old (P-value <0.01). Eighty-six percent of those under 65 years of age indicated they would be interested in receiving at least one service, while only 73% of those 65 years or older reported the same interest (P-value <0.01). Other between-group differences were not found to be statistically significant.

Nearly the same proportion (80%) of individuals indicated they would be interested in purchasing a monthly pharmacy-based health membership plan for their hypertension (Table 3). Of the 278 interested in health membership plans, 66% were more interested in the comprehensive or premium health plan and 34% were more interested in the basic health plan with fewer services. Although individuals who were <65 years old had a longer history of hypertension and usually purchased brand name or brand name + generic medications were more interested in a monthly health plan, these differences were not statistically significant (P-value for binary age = 0.1765; P-value for hypertension history = 0.3654; P-value for medication type = 0.1125).

Table 3.

Patients’ interest and readiness-to-pay for monthly hypertension management packages

	All patientsa	Age		Time since diagnosis		Of patients taking medications regularly, type of medication usually purchased
	N = 347 (100%)	<65 years old N = 214 (62%)	≥65 years old N = 133 (38%)	≤10 years N = 202 (59%)	<10 years N = 140 (41%)	Generic only N = 207 (65%)	Brand name or both brand name + generic N = 111 (35%)
Interested in receiving pharmacy-based health membership packages
% Yes, interested in at least one package	278 (80.4%)	176 (82.6)	102 (76.7%)	165 (81.7%)	108 (77.7%)	159 (77.2%)	94 (84.7%)
% Interested in basic plan	94 (33.8%)	55 (31.3%)	39 (38.2%)	48 (29.1%)	46 (42.6%)	59 (37.1%)	29 (30.9%)
% Interested in premium plan	184 (66.2%)	121 (68.8%)	63 (61.8%)	117 (70.9%)	62 (57.4%)	100 (62.9%)	65 (69.2%)
% No, not interested in either package	68 (19.7%)	37 (17.4%)	31 (23.3%)	37 (18.3%)	31 (22.3%)	47 (22.8%)	17 (15.3%)
% Patient already has health insurance	51 (75.0%)	32 (86.5%)	19 (61.3%)	26 (70.3%)	25 (80.7%)	37 (80.4%)	10 (61.1%)
% Doesn’t think services are necessary	9 (13.2%)	3 (8.1%)	6 (19.4%)	7 (18.9%)	2 (6.5%)	4 (8.7%)	4 (22.2%)
% Packages don’t offer services that patient needs	0 (0.0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
% Other or no reason given	8 (11.8)%	2 (5.4%)	6 (19.4%)	4 (10.8%)	4 (12.9%)	5 (10.9%)	3 (16.7%)
% No response	1 (0.3%)	1 (0.5%)	0 (0.0%)	0 (0.0%)	1 (0.7%)	1 (0.5%)	0 (0.0%)
Among those interested in health membership packages, amount patients indicated they would pay for each potential hypertension membership packageb
Basic plan
≤$3.69 US	89 (95.7%)	52 (94.6%)	37 (94.9%)	44 (91.7%)	45 (97.8%)	57 (96.6%)	27 (93.1%)
$3.70–$11.05 US	4 (4.3%)	3 (5.5%)	1 (2.6%)	3 (6.3%)	1 (2.2%)	2 (3.4%)	1 (3.5%)
>$11.05 US	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
No response	1 (1.1%)	0 (0%)	1 (2.6%)	1 (2.1%)	0 (0%)	0 (0%)	1 (3.5%)
Premium plan
≤$3.69 US	120 (65.9%)	80 (66.1%)	40 (63.5%)	74 (63.3%)	42 (67.8%)	68 (68.0%)	43 (66.2%)
$3.70–$11.05 US	53 (29.1%)	34 (28.1%)	19 (30.2%)	36 (30.8%)	16 (25.8%)	27 (27.0%)	17 (26.2%)
>$11.05 US	9 (4.9%)	5 (4.1%)	4 (6.4%)	7 (5.98%)	2 (3.2%)	5 (5.0%)	3 (4.6%)
No response	2 (1.1%)	2 (1.7%)	0 (0%)	0 (0%)	2 (3.2%)	0 (0.0%)	2 (3.1%)

Italicized estimates represent patient responses to the parent question of whether they were interested in either proposed health membership plan. Column totals of these cells sum to 100% (% Yes, interested in at least one package; % No, not interested in either package; % No response).

^aNot all sub-categories total to 347 respondents due to missing data. Missing and non-missing respondents were not meaningfully different.

^b2012 Peruvian Nuevos Soles converted to 2015 U.S. Dollars using World Bank Official Exchange Rate and Consumer Price Indices. Survey originally asked clients ranges of Nuevos Soles (≤10 N. Soles, 11–30 N. Soles, 31–60 N. Soles, >60 Nuevos Soles).

However, 20% of individuals were not interested in the health membership plans for hypertension. Of these 68 individuals, most (75%) indicated their disinterest was based on currently having health insurance. Another 13% indicated they did not think the services were necessary, and 12% indicated lack of interest due to some other reason (Table 3).

Finally, the study evaluated readiness-to-pay for monthly health membership plans. Of those individuals interested in purchasing the premium health plan, most (70%) indicated they would pay $3.69 US or less per month. Another 29% stated they would pay between $3.70 and $11.05 per month, while only 5% would pay more than $11.05 per month. Of the 94 individuals interested in receiving the basic health plan, the vast majority (96%) indicated they would only pay the lowest category offered in the survey: $3.69 US or less per month. These findings were similar across demographic characteristics (P-value = 0.4596) (Table 3).

Results from the multiple logistic regression indicated that individuals who reported visiting a doctor to check their blood pressure less than quarterly had 83% lower odds of stating they would pay for a health membership plan compared to those who saw the doctor monthly, controlling for other demographic variables (OR = 0.17, 95% CI: 0.0528–0.5560) (Table 4). Individuals who reported higher monthly expenses (<$3.69 per month) for hypertension had 3.6–6.2 times higher odds of stating they would pay for a health membership plan compared to those who reported the lowest monthly expenses (≤$3.69), controlling for other demographic variables (P-value <0.05) (Table 4).

Table 4.

Readiness-to-pay for potential hypertension management packages, if offered by private pharmacies, by client characteristics^a

Characteristics	% Ready to pay for any package	% Not ready to pay for either package	Odds ratio
	N = 278 (80%)	N = 68 (20%)	Ref. = 1.00 (95% CI)
All patients
Age (mean, range)	62.25 (39–91)	64.13 (38–85)	1.01 (0.98, 1.04)
Time since hypertension diagnosis
<5 years	104 (38.0%)	24 (35.3%)	1.00
5–10 years	61 (22.3%)	13 (19.1%)	0.78 (0.34, 1.82)
>10 years	109 (39.8%)	31 (45.6%)	0.72 (0.35, 1.49)
Type of medication usually purchased for blood pressure
Generic	160 (63.0%)	47 (73.4%)	1.00
Brand name or both brand name + generic	94 (37.0%)	17 (26.6%)	1.11 (0.56, 2.21)
Frequency of visits to doctor to check blood pressure
Once per month	179 (65.8%)	42 (62.7%)	1.00
Once every three months	81 (29.8%)	18 (26.9%)	0.98 (0.50, 1.93)
Less than once every three months	12 (4.4%)	7 (10.5%)	0.17 (0.05, 0.56)
Average amount currently spend on medicines and medical care for hypertension each monthb
≤$3.69 US	129 (46.6%)	53 (77.9%)	1.00
$3.70–$11.05 US	73 (26.4%)	8 (11.8%)	4.56 (1.86, 11.22)
$11.06–$22.12 US	37 (13.4%)	4 (5.9%)	3.62 (1.09, 12.06)
>$22.12 US	38 (13.7%)	3 (4.4%)	6.17 (1.63, 23.36)

^aAnalysis does not include missing data. Missing and non-missing respondents were not meaningfully different.

^b2012 Peruvian Nuevos Soles converted to 2015 U.S. Dollars using World Bank Official Exchange Rate and Consumer Price Indices. Survey originally asked clients ranges of Nuevos Soles (≤10 N. Soles, 11–30 N. Soles, 31–60 N. Soles, >60 Nuevos Soles).

Discussion

This study evaluated the acceptability of pharmacy-based services in Lima, Peru to support hypertensive individuals in better managing and controlling their hypertension. Over 80% of individuals who participated in the study were interested in using pharmacy-based services, beyond basic medication dispensation, to help them better manage their disease.

Individuals younger than 65 years old were more interested in receiving hypertension services in the pharmacy than older individuals. Adults older than 65 years old were more likely than those less than 65 years old to state that they did not think pharmacy-based services were necessary and less likely to cite current insurance coverage as the reason that they were not interested. Seniors might have greater concerns about potential costs or have a lack of trust in receiving preventive care (e.g., blood pressure screening) through a pharmacy compared to a doctor’s office. Alternatively, survey respondents may not have been familiar with pharmacy-based clinical services, since clinical services are currently only offered in select pharmacy locations. More information is needed on patient’s perceptions of pharmacies as a non-traditional health care access point in Peru and other LMICs.

Despite the greater interest among individuals <65 years old, a vast majority (approximately 80%) of all respondents were interested in receiving standalone services and purchasing a monthly health plan through the pharmacy to help manage their hypertension. This finding in itself is valuable to decision-makers aiming to provide more accessible, patient-centered services that simultaneously meet individuals’ needs and improve population health. Given the higher level of interest among those under 65 years old, uptake of pharmacy-based services might be greater within this demographic. Pharmacies considering providing services for hypertension and chronic disease management could consider developing services targeted to specific age groups to ensure uptake and more efficiently improve treatment and disease control.

Most patients were interested in purchasing the most comprehensive plan suggested, but would not pay more than $11.05 for these services. To be successful in attracting long-term clients and developing sustainable programs that support public health goals, pharmacies interested in establishing programs to improve chronic disease management should consider creating business models that find the intersection between comprehensiveness and affordability.

Patients in the study were more likely to indicate they would pay for a monthly health membership plan if they already saw a doctor more regularly for blood pressure checks and spent more on medications and medical visits related to their hypertension. This suggests pharmacy-based hypertension services may be most successful with individuals who are already actively engaged in their care and are willing and able to pay for health care services in and out of the pharmacy. However, most patients who were not interested in purchasing health plans cited current insurance coverage as the reason they did not find the pharmacy-based services appealing. Therefore, it is possible that individuals who reported paying the most for their health care currently are uninsured or under-insured and could benefit from lower-cost care through the pharmacy to supplement the care they currently receive elsewhere. The survey did not collect information about the type of insurance coverage or health care services that participants usually received. Additional research eliciting patient acceptability by insurance status could help identify groups that would most benefit from services offered through non-traditional access points, such as pharmacies.

In addition, the service of primary interest to survey respondents was discounts on medications. In Peru, adherence to anti-hypertensive medications is low,³⁰ yet medication costs for patients can be high.³¹ For example, 30% of the patients in the study reported taking Losartan; a monthly cycle of this drug in Peru has been estimated to cost more than $50 US (19% of the monthly minimum wage in Peru) for those paying out-of-pocket.³¹ These findings suggest that patients would like to pay less for their medications, which may help with accessibility and adherence.

Furthermore, 66% of patients indicated they would like to receive blood pressure screenings and regular check-ups through the pharmacy, suggesting that individual demand for specialized services is strong. Several pharmacies in Peru already offer blood pressure screenings³¹; however, these programs may charge a fee and are not yet well established. Incorporating services into a formal, monthly health plan might improve continuity of care and yield health benefits for reduced costs. A systematic review and meta-analysis of trials evaluating pharmacist-directed hypertension management programs in low-, middle-, and upper-income countries found that monitoring hypertensive people in pharmacies can lead to a significant reduction in cardiac events and related costs while improving patients’ quality of life.¹³

It is important to note that this study only included individuals with a known diagnosis of hypertension who were purchasing anti-hypertensive medications in a pharmacy in Lima at the time of the survey. As such, the study results may not be representative of the entire population of patients with hypertension. Rather, the findings may support the development of programs and services targeted toward individuals in Lima who are diagnosed and following a treatment plan. Limited data exists on usual adherence rates in Peru, and better pharmacovigilance programs are needed to estimate this information on a national level. One study of hypertensive patients in an outpatient clinic of a large national hospital in Lima found that 57% of patients prescribed anti-hypertensives had low levels of adherence based on definitions from the Morisky Medication Adherence Scale-8.³⁰ Research suggests only 48% of hypertensive individuals in Peru know they have hypertension; only 40% are treated, and of those treated, only 11% have their hypertension under control.⁷ Studies in Brazil, Portugal and Pakistan, among other countries, indicate that pharmacy-based programs with an education component may improve medication adherence for hypertensive patients.^16,32,33 Pharmacies might also consider providing patient support for lifestyle habits (e.g., education on healthy diet and physical activity, weight loss groups, etc.) to patients as part of their monthly health plan to assist in disease management and medication adherence. Finally, future projects should consider developing and evaluating pharmacy-based programs tailored to individuals with co-morbidities accompanying hypertension (e.g., diabetes).

To the authors’ knowledge, only a few studies have been conducted assessing patient acceptability of and satisfaction with pharmacy-based hypertension services in LMICs. One study in Ghana found that patients were generally receptive to receiving blood pressure screening from pharmacists; others conducted in Nigeria and India reported high levels of patient satisfaction with pharmacist-led hypertension management services.^17,34,35 As the global community turns more frequently to non-physician providers and non-traditional access points to help alleviate the growing burden associated with hypertension and other chronic diseases, patient perceptions and preferences for the design of health delivery systems and disease management programs should be considered.³⁶

This study has some limitations. First, individuals in the study population were purchasing medications at the time of the survey, indicating that this population has the ability and motivation to pay for at least some services to control their disease, which may not be reflective of the general population in Peru. The survey did not collect information about sex, education or health literacy levels, income, insurance coverage, current source of health care services, or frequency of pharmacy use. These characteristics, and particularly income and insurance coverage, would likely influence an individual’s readiness-to-pay for a pharmacy-based hypertension management program and should be explored in future research. The survey refusal rate was not captured, and thus, it is difficult to determine whether individuals who were approached but declined participation in the study were meaningfully different in any way from the study group.

Finally, the health plan offerings included in the study should be evaluated for potential effectiveness and patient satisfaction. However, this was outside of the scope of the study. Measuring patient interest and acceptability prior to implementing and evaluating a new intervention is a prudent first step in the development of new, patient-centered health care programs. Private pharmacies may be concerned about investing in program development and evaluation without knowing whether their customers would actually be interested in the program offerings in the first place. Assessing upfront acceptability of potential services can inform future program development and generate hypotheses for future research, while also informing and improving service offerings. Future studies should consider evaluating the acceptability, feasibility and impact of pharmacist-provided education for hypertension and other chronic diseases.

Patient uptake and ability to pay for services is critical to the success of any program, and this study can guide ministries of health and private pharmacies in LMICs that match the needs of hypertensive consumers. In addition, this study offers information about patient perceptions of a novel approach to improving access to and affordability of care for individuals with hypertension. Results from this study may be relevant to pharmacies considering offering pharmacy-based programs for other non-communicable diseases, such as diabetes, cardiovascular issues, obesity, and hyperlipidemia. For example, many individuals in the study indicated they would be interested in receiving lab tests and consultations through the private pharmacy setting. These services would likely be important to individuals with other, similar disease states beyond hypertension.

As the role of the pharmacy becomes more integral in a comprehensive approach to hypertension prevention and management worldwide, the findings from this study suggest that patients in Peru and other LMICs may be willing to use services provided through this non-traditional access point. Future studies evaluating pharmacy-based chronic disease management programs will identify facilitators and barriers to this approach to care, as well as the expanding roles pharmacists and pharmacy technicians can play in disease management strategies. Additional work should evaluate the potential for subscription-based programs – such as monthly health membership plans – to improve key disease control outcomes such as medication adherence and blood pressure in countries where loss to follow-up is high and rates of hypertension control are low. Innovative pharmacy-based approaches to hypertension management may better engage patients in their care and leverage existing resources in the private market to improve population health outcomes.

Supplementary Material

Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.sapharm.2016.05.049.