Abstract
This cross-sectional study examines the health characteristics of individuals who use mail-order pharmacies.
Widening deficits for the US Postal Service have led to operational changes that have delayed deliveries.1 Many Americans, particularly elderly individuals,2 rely on mail-delivered medications, raising concerns that delays could have medical repercussions.
Methods
To assess the role of mail-delivered prescription medications, we analyzed the 2018 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the noninstitutionalized US population. The MEPS asks respondents about all new and refill prescriptions, including the types of pharmacies (eg, drugstore, another store, clinic/hospital, online, mail order) used during the survey round (covering 4-5 months).
We defined mail-order prescriptions as those received by a respondent reporting only mail-order pharmacy use during that survey round, and tabulated the numbers, names, and therapeutic class of those prescriptions. Because the type of pharmacy was specific to the individual and survey round, not individual prescriptions, we could not calculate total mail-order prescription purchases. Next, we identified persons who received any mail-order prescription in 2018 and those who received only mail-order prescriptions. We tabulated these users' self-reported health characteristics, including 7 chronic diseases and 4 functional disabilities that might impede travel to a retail pharmacy, like difficulty performing errands alone or seeing (even with eyeglasses).
We used Stata/SE, version 16.1 svy (StataCorp) procedures to account for complex sample design and MEPS weights to produce national estimates. This analysis of deidentified, publicly available data was not considered human participants research, and thus was exempt from review by the Cambridge Health Alliance institutional review board.
Results
Our sample included 12 700 mail-order prescription fills (weighted n = 133.7 million) delivered nationwide in 2018 (Table 1). Cardiovascular agents were the most common therapeutic class (32.1 million [24.0%]). Several classes of medications for which supply interruptions might pose a hazard were commonly mail ordered, including coagulation modifiers (3.9 million [2.9%]), antineoplastic agents (1.1 million [0.8%]), and respiratory agents (5.7 million [4.3%]). There were more than 1 million mail-order fills each for warfarin and clopidogrel, and 0.8 million for contraceptives (data not shown).
Table 1. Number of Prescriptions Delivered to Individuals Exclusively Using Mail-Order Pharmacies by Therapeutic Class During 2018.
| Therapeutic classa | Weighted No. (95% CI), thousands |
|---|---|
| Cardiovascular agents | 32 114 (27 377-36 850) |
| Metabolic agents | 26 755 (22 447-31 062) |
| Central nervous system agents | 19 765 (14 668-24 863) |
| Psychotherapeutic agents | 9656 (6676-12 635) |
| Hormones/hormone modifiers | 7764 (6116-9412) |
| Gastrointestinal agents | 7047 (5416-8679) |
| Respiratory agents | 5711 (3860-7562) |
| Topical agents | 5701 (4106-7295) |
| Nutritional products | 3961 (2717-5205) |
| Coagulation modifiers | 3891 (2852-4931) |
| Not ascertained | 3509 (2510-4507) |
| Anti-infectives | 3297 (1996-4599) |
| Miscellaneous agents | 2331 (1292-3371) |
| Antineoplastics | 1092 (541-1644) |
| Genitourinary tract agents | 797 (476-1117) |
| Alternative medicines | 185 (19-350) |
| Immunologic agents | 134 (0-272) |
| Biologicals | 0 |
| Total | 133 709 (114 046-153 373) |
According to the primary Multum Lexicon therapeutic classification of the prescribed agent.
Table 2 displays characteristics of the 2246 participants (weighted n = 25.3 million) who were mail-order users, including 625 (26.9%; weighted n = 6.8 million) who relied exclusively on mail order. Persons relying on mail order for all medications had similar health and rates of disabilities as all mail-order users. A total of 13.8 million mail-order users (56.4%) had hypertension, 7.1 million (28.9%) had heart disease, and 6.1 million (23.9%) had diabetes. Among mail-order users, 5.1 million (20.4%) had difficulty walking 3 blocks, 2.6 million (10.4%) reported difficulty doing errands alone, almost 1 million (3.6%) had difficulty seeing, and 1.3 million (5.3%) had difficulty dressing/bathing.
Table 2. Health and Functional Disabilities of US Users of Mail-Order Pharmacies During 2018a.
| Characteristic | Mail-order pharmacy users (n = 2246) | Mail-order pharmacy exclusive users (n = 625) | ||
|---|---|---|---|---|
| Proportion (95% CI) | Weighted No. (95% CI), thousands | Proportion (95% CI) | Weighted No. (95% CI), thousands | |
| Age ≥65 y | 47.9 (45.0-50.8) | 12 069 (11 012-13 126) | 49.9 (45.1-54.7) | 3358 (2922-3794) |
| Fair/poor health | 16.7 (14.9-18.6) | 4156 (3635-4677) | 15.2 (12.1-18.9) | 1016 (762-1271) |
| Chronic diseases | ||||
| High blood pressure | 56.4 (53.8-59.0) | 13 823 (12 785-14 860) | 57.0 (52.1-61.8) | 3715 (3195-4235) |
| Heart diseaseb | 28.9 (26.7-31.2) | 7083 (6331-7834) | 27.6 (23.5-32.0) | 1797 (1488-2106) |
| Stroke | 8.3 (7.1-9.6) | 2026 (1715-2337) | 8.5 (6.5-11.2) | 556 (390-722) |
| Asthmac | 10.6 (9.1-12.4) | 2661 (2209-3114) | 8.3 (6.2-11.0) | 549 (378-720) |
| COPDd | 5.7 (4.8-6.7) | 1389 (1155-1622) | 4.6 (3.1-6.7) | 296 (182-411) |
| Cancer history | 23.7 (21.5-26.1) | 5807 (5067-6547) | 25.9 (21.9-30.4) | 1690 (1344-2036) |
| Diabetes | 23.9 (21.9-26.1) | 6055 (5366-6744) | 19.9 (16.7-23.5) | 1347 (1073-1620) |
| Disabilities | ||||
| Difficulty walking 3 blockse | 20.4 (18.3-22.5) | 5126 (4498-5754) | 17.6 (14.3-21.4) | 1191 (918-1465) |
| Difficulty seeing (with eyeglasses) | 3.6 (2.8-4.6) | 905 (681-1129) | 3.7 (2.4-5.6) | 247 (135-359) |
| Difficulty doing errands alone | 10.4 (9.1-12.0) | 2573 (2175-2972) | 9.4 (6.9-12.7) | 615 (423-807) |
| Difficulty dressing/bathing | 5.3 (4.3-6.5) | 1324 (1028-1620) | 4.7 (3.1-6.8) | 312 (189-434) |
Abbreviation: COPD, chronic obstructive pulmonary disease.
Numbers analyzed among 2246 mail-order pharmacy users for each outcome: 2232 (age), 2216 (health status), 2176 (high blood pressure); 2176 (heart disease), 2176 (stroke); 2216 (asthma); 2166 (COPD); 2176 (cancer); 2245 (diabetes); 2233 (difficulty walking); 2231 (difficulty seeing); 2176 (difficulty doing errands alone); and 2223 (difficulty dressing).
Persons reporting a diagnosis of coronary heart disease, angina, myocardial infarction, or other heart disease.
Persons with current asthma only.
Persons reporting either a diagnosis of emphysema or chronic bronchitis within past 12 months.
Includes individuals with some difficulty, a lot of difficulty, or unable to do.
Discussion
The US Postal Service has been delivering medications for more than a century, initially to remote areas.3 The Veterans Health Administration was the first health system to offer routine mail delivery,3 and by 2016, approximately 80% of these prescriptions were mailed.4 Overall, about 5.8% of the approximately 4 billion annual prescriptions are mail ordered.5
Many studies address medication adherence, and some data suggest that mail-order delivery improves it and possibly outcomes like low-density lipoprotein cholesterol levels.6 However, we are unaware of research on noncompliance caused by problems in the prescription delivery infrastructure, nor of the health characteristics of mail-order users. Dosing interruptions of drugs, such as contraceptives, seizure medications, and anticoagulants, may cause serious adverse effects, particularly because, as we find, many patients reliant on mail-order drug delivery have disabilities (like serious visual impairments) that could hamper their ability to travel to brick-and-mortar pharmacies.
Our study has limitations. We could not assess the outcomes of delivery delays. Our figures, although the latest available, predate the pandemic, and likely understate mail-order deliveries currently.5 Additionally, they exclude prescriptions ordered online or from local pharmacies that might also be delivered by mail, and prescriptions mailed to respondents using multiple pharmacy types during the survey round.
Many Americans now rely on the US Postal Service, the only home-delivery option in some locales, to assure timely receipt of medications. Delays in mail deliveries may compromise access to important medications for millions of medically vulnerable Americans.
References
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