Systemic barriers in receiving electronically prescribed glaucoma medications

Abstract

Purpose:

Glaucoma treatment relies on long-term medication compliance and many socioeconomic factors impact the ability of patients to receive their medications. This study aims to quantify treatment interruptions attributable to electronically prescribed medications and propose interventions to minimize this barrier.

Methods:

This is a cross-sectional study of the electronic prescribing patterns at a tertiary care hospital serving a socioeconomically diverse patient population. Glaucoma medication refill requests received over a six-week interval were reviewed and patient pharmacies were contacted one month following the request date to determine if the medication was received by the patient. Patients who did not pick up the prescriptions were contacted and consented to participate in a survey to identify the barriers to acquiring the medications.

Results:

Refill requests of 198 glaucoma medications met the inclusion criteria and the most common classes were prostaglandin analogs (44%) and alpha-2-agonists (21%). Medications were not obtained within one month in 71 (35.9%) cases. Prior authorization requirement was significantly associated with patients not obtaining their medication (OR, 0.07; 95% CI, 0.03–0.45). Patient reported challenges to successful receipt electronically prescribed medications included insurance coverage (32.2%) and pharmacy availability (22.6%).

Conclusions:

Approximately a third of electronically prescribed glaucoma medications were not received by patients within a month of refill request due to the need for prior authorization, insurance coverage, and pharmacy availability. A mechanism to alert providers and to address these barriers to medication access may minimize treatment interruption and disease progression.

PRECIS

Over a third of electronically prescribed glaucoma medications were not picked up within one month of patient request. Feedback-driven protocols may help minimize treatment interruptions attributed to electronic prescribing.

INTRODUCTION

Medical treatment of glaucoma relies on the use of daily topical medications to decrease intraocular pressure (IOP) and prevent disease progression,¹ and treatment compliance is a multifactorial challenge.^2–4 Boston Medical Center (BMC) is the primary safety net hospital in the greater Boston area and serves a socioeconomically diverse patient population.⁵ Approximately 75% of patients come from underserved populations and many rely on government payers such as Medicaid and Medicare for their insurance coverage. We hypothesize that systemic challenges in electronic prescribing may disproportionately affect individuals in a predominantly lower socioeconomic community. This investigation aims to assess whether electronically-prescribed glaucoma medications reach patient pharmacies, and more importantly, if patients physically obtain the medications. We hope to identify the systemic barriers to medication access and propose mechanisms to address access-related glaucoma disease burden.

METHODS

The BMC Institutional Review Board (IRB) approved the retrospective review of patient records and cross sectional patient survey (IRB-H-34830). Informed consent was waived for the medical record review and obtained for those patients participating in the follow-up survey. This study adhered to the tenets of the Declaration of Helsinki and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.⁶

Patients were identified for inclusion in the study using the BMC electronic prescription refill system. The study was performed in January and February 2017 following a hospital-wide transition to electronic prescribing. We included all patients with a glaucoma prescription request over a six-week interval. We excluded patients under 18 years of age and those without previous evaluation, diagnosis and treatment for glaucoma suspicion, primary open angle glaucoma, or ocular hypertension. All of the refill requests in this study were patient-initiated and for medications with less than one month supply remaining. Patients were expected to be able to obtain the medication within this time frame in order to avoid treatment interruption. Electronic prescriptions were sent to pharmacies based on patient preference, with most patients choosing a pharmacy close to their homes.

Pharmacies were prospectively contacted one month following the date of patient-requested refill to determine if the medications were picked up by the patient. For medications not picked up, a phone call was made to the patient, and if reached, informed consent was obtained verbally to inquire as to why the medications were not received. Patients were asked if they were able to receive the medication, and if not were asked to provide the reasons for not receiving the medication. In addition, patients were specifically asked if there were any insurance or cost-related contributions. Finally, patients had the option of providing any suggestions on improving the electronic prescribing process. The survey questions used in this study are summarized in eSupplement 1.

The primary outcome was the percentage of medications prescribed electronically that were not successfully picked up within one month of patient request. In addition, we qualitatively described the most common barriers to medication receipt from the telephone survey. We further explored associations between medication receipt and type of prescribed medication using univariate logistic regression models. The binary outcome of the regression model was successful receipt of the medication. The predictors included categorical variables for class of medication (prostaglandin analog, alpha-2-agonist, and beta-blocker) and prior authorization requirement. A multivariable model was also developed including both covariates. Odds ratios (OR) and 95% confidence intervals (CI) were reported from the regression models. All statistical tests were two-tailed with significance defined at p < 0.05. All analyses were performed using R version 4.1.0 (R Core Team, 2021).

RESULTS

During the study period, 292 medications from 232 patients were requested through the BMC electronic prescription refill system. After review, 198 medications from 145 patients met the inclusion criteria of patient-requested glaucoma medication refills.

Of these medications, 127 (64.1%) were successfully obtained by the patient within one month of patient request. The most common medication classes were prostaglandin analogs (44%), alpha-2-agonists (21%), and beta-blockers (20%). The majority of medications which were not successfully obtained were filled by the pharmacy, but not picked up by the patient (56.3%) and the remainder were not picked up due to problems identified with insurance coverage (32.2%), pharmacy availability (22.6%), or a physician recommended change in medical therapy after the patient-request had been made (38.7%) (Table 1).

Table 1:

Outcomes of electronically prescribed glaucoma medication refill requests. The majority of medications were picked up by patients; however, over 1/3rd (35.8%) of medications requested were not obtained.

Response/Reason	Count	Percent
Yes	120	61%
Yes, but delayed	7	4%
Insurance	4	57%
Too Early for Refill	3
Incorrect Personal Information	1
Pharmacy	2	29%
Patient switched pharmacy	1
Medication out of stock	1
Prescribing Error	1	14%
Filled, not yet retrieved per pharmacy	40	20%
Travel	7	18%
Transportation Difficulties	1
Setting up Delivery Service	3
Left the Country	3
Insurance	2	5%
Prior Authorization Delay	1
Patient Action Required	1
Delay without Obstacle	1	3%
Unknown	30	75%
No	31	16%
Insurance	10	32%
Prior Authorization Denied	5
Prior Authorization Pending	1
Copay is too high	1
Insurance does not cover medication	2
Patient is uninsured	1
Physician Discontinued	12	39%
Therapy completed	7
Patient needs an appointment	1
Medication changed	1
Narcotics not indicated	1
Unspecified	2
Pharmacy	7	23%
Medication out of stock	2
Electronic Rx not received	3
Unable to reach patient	2
Unknown	2	6%
Total Medication Requests	198	100%

The logistic regression model did not demonstrate a significant association between successfully obtaining a medication and the class of glaucoma medication (all p > 0.05). However, medications requiring prior authorization were significantly less likely to be received by patients (OR, 0.07; 95% CI, 0.04–0.45) (Figure 1 and eSupplement 2). The reasons for not receiving the medication expressed by patients who consented to the phone interview included expensive co-payment, delays due to prior authorization error, and personal challenges in travelling to the pharmacy.

Figure 1:

Odds ratios of successful receipt of medication from multivariable logistic regression. There was no significant association between class of glaucoma medication. However, there medications requiring prior authorization were significantly less likely to be successfully received by the patient.

DISCUSSION

Our results suggest that physical receipt of electronically prescribed glaucoma medications may be a major barrier to treatment compliance in our patient population. We found that over a third of patients had not received their requested medication at least one month after submitting a request. It is difficult to measure the clinical impact of this treatment delay as the total duration of time without medication is unclear. In the best-case scenario, patients may already have an adequate reserve of medication to last through the temporary delay. In the worst-case scenario, patients may have already run out of the requested medication. In the latter situation, any delay in medication receipt may affect patient confidence or trust in the provider or practice, which could decrease future adherence to treatment recommendations. The impact of these treatment interruptions on clinical outcomes such as IOP control and glaucoma disease progression could not be quantified in this study design, but deserves further investigation. Future research is warranted to identify specific risk factors for individuals recurrently affected by challenges with electronically prescribed medications and may reveal insight into loss to follow-up and adverse outcomes due to treatment interruption.

We identified several systemic errors in the prescription refill process that have been described previously in the primary care literature, but not in the ophthalmic literature, including software errors resulting in the medication never reaching the pharmacy, communication errors causing delays at the pharmacy, and processing errors from duplicate or discontinued medication requests.^7–9 Of the medications not successfully obtained, we believe the majority were for reasons which could be addressed and minimized by a systemic feedback-based intervention. Based on our findings, we highlight three areas of feedback, that if optimized, could potentially increase the probability of successful medication receipt. First, over half of our cohort did not pick up a medication already filled and available at their pharmacy. Automated feedback to the provider that a prescription has not been picked up would allow the provider’s office to minimize treatment delay by contacting the patient directly. Such an intervention would serve as an additional feedback loop would be beneficial in addition to the current mechanisms by which pharmacies use to contact patients. Second, several prescriptions were not received by the pharmacies, and thus, providers would benefit from an automated notification system alerting successful receipt and/or errors in electronic prescribing. Third, any insurance coverage or prior authorization issues should also be flagged by the pharmacy and routed to the provider’s office with suggestions for covered alternatives to expedite successful requests. The co-payment system is variable in our patient population, and frequent changes in insurance coverage lower the predictability of out-of-pocket expenses. An electronic feedback system within the framework of the EMR would be the most direct. These areas of focus emphasize the importance of a robust communication system between providers and pharmacies.¹⁰

Despite the challenges identified in our cohort, there are many potential benefits of electronic prescribing for medication refills.⁹ Pharmacies report overall increased processing speeds for electronic requests,⁷ and providers also spend less time overall prescribing electronically despite concerns for a decline in face-to-face time with patients.¹¹ Time saved by providers and pharmacies can translate into dollars saved by the health care system.¹² Benefits also include improving medication safety^13–15 and patient experience.¹⁶ Limitations of our study include the cross-sectional design, which limits our ability to quantify the clinical impact of treatment disruption. We hope future prospective investigations can compare the ability of feedback at various stages of our electronic prescription workflow to increase the percentage of successfully obtained prescriptions. We also experienced challenges in contacting many of the patients for the follow-up survey, which likely reflects similar difficulty pharmacies encounter in reaching patients, and suggests the need to verify patient contact information at each visit in addition to a strategy that uses multiple contact methods such as text messages and emails, in addition to phone calls. For those subjects interviewed, there is potential for recall bias to underestimate certain less time- or resource-consuming barriers to medication receipt. Finally, although our findings may reflect challenges with medication adherence in other chronic medical conditions,¹⁷ the specific results of our study may not necessarily be generalizable to other types of medications or different electronic prescribing infrastructure. We hope this study highlights the necessity of active feedback and collaboration between providers and pharmacies to ensure that patients are receiving electronically prescribed glaucoma medications.