Association between community pharmacy loyalty and persistence and implementation of antipsychotic treatment among individuals with schizophrenia
Introduction
Antipsychotics represent the cornerstone of schizophrenia management for many individuals.1 Medication adherence, that is the extent to which a person's behaviour corresponds with agreed recommendations from a healthcare provider,2 is key to fully benefit from antipsychotic treatment. Medication adherence is a multidimensional construct that includes initiation (the extent to which a newly prescribed drug treatment is undertaken), persistence (the extent to which the drug treatment is taken for the prescribed duration) and implementation (the extent to which the drug treatment is taken at the recommended dose).3, 4
However, both non-persistence and suboptimal implementation are widespread among individuals prescribed antipsychotics. In a study conducted in the province of Quebec (Canada), 32.5% of individuals with schizophrenia insured by the public drug plan were non-persistent with their atypical antipsychotics one year after initiation.5 Among those who were persistent, 21.4% were judged as having suboptimal implementation, defined as having an antipsychotic in their possession for < 80% of the days. Based on a review of five studies, Lacro et al.6 found that 49.5% (weighted mean by sample) of individuals with schizophrenia did not take their antipsychotic treatment for at least 75% of the total number of days, for periods varying from 1 month to 2 years. In another study, only 55% of individuals with schizophrenia were considered persistent and reported to have taken 100% of their antipsychotics in the week preceding the study, with antipsychotic serum concentration within reference values.7
Suboptimal implementation of antipsychotic treatment has been associated with higher risk for relapse,8, 9 hospitalization,10, 11 and visits to the emergency room.12, 13 For example, a study showed that individuals who had an antipsychotic for less than 80% of the total days were 55% more likely to be hospitalized (OR 1.55; 95% CI 1.21–1.98) and 49% more likely to use emergency psychiatric services in the following two years (OR 1.49; 95% CI 1.12–1.98) when compared to those having an antipsychotic for ≥80% of the days.12
Community pharmacists are in a key position to detect non-adherence, identify its causes, and put in place interventions. Some trials indicate that pharmacy-based interventions could improve adherence among individuals with mental illness.14, 15 It is likely that the pharmacist's work could be facilitated and be more efficient when an individual is loyal to a single pharmacy meaning that s/he refills all his/her prescriptions at the same pharmacy. In the province of Quebec (Canada), it is mandatory for community pharmacists to maintain a pharmacy record with detailed information on all the prescriptions that have been dispensed to an individual. However, these records are not necessarily shared between pharmacies or pharmacy chains. In this context, a high community pharmacy loyalty level implies that the pharmacist has more complete information on drugs claimed by an individual and that s/he could more easily use these records to detect non-adherence. In addition, a high level of community pharmacy loyalty could facilitate patient-pharmacist collaboration, the implementation and follow-up of the pharmacist's adherence-enhancing interventions as well as the collaboration with other healthcare professionals.
Community pharmacy loyalty has been studied in the general population16, 17 and among individuals with multiple chronic illnesses18, 19 or a single illness such as diabetes20 or cardiovascular disease.21 The association between community pharmacy loyalty and implementation was assessed in four of these studies.18, 19, 20, 21 As opposed to individuals who had their prescriptions filled in a single pharmacy, those who had them filled in multiple pharmacies were more likely to have lower levels of treatment implementation.18, 19, 20, 21 Our team has studied to what extent individuals with schizophrenia had their prescriptions filled at a single pharmacy.22 Results indicated that 42.2% of individuals were dispensed their drugs in more than one pharmacy in the year after treatment initiation.22 As an important proportion of individuals treated for schizophrenia were filling their prescriptions in multiple pharmacies, a study was undertaken to determine the association between community pharmacy loyalty and persistence with and implementation of antipsychotics. Specific objectives of this study were:
- 1)
To estimate the association between the level of community pharmacy loyalty and persistence with antipsychotics on the 730th day after antipsychotics initiation;
- 2)
Among persistent individuals, to estimate the association between the level of community pharmacy loyalty and implementation of antipsychotics in the second year after antipsychotics initiation.
Section snippets
Study design
A cohort study of individuals diagnosed with schizophrenia who initiated antipsychotics and who were insured with the Quebec's public drug plan administered by the Quebec health insurance board (Régie de l'assurance-maladie du Québec (RAMQ)) was conducted. This public drug plan covers all residents who do not have a private group plan drug insurance, individuals aged ≥65 years, and welfare recipients.23
The level of community pharmacy loyalty was measured in the 365 days after antipsychotics
Results
A total of 6,251 individuals with schizophrenia were included in the study (Fig. 2). Their characteristics are presented in Table 1. Among them, 52.3% were male and 65.0% were aged between 30 and 64 years. The majority (86.9%) were living in an urban area and 71.0% were recipients of GIS. Antipsychotics were prescribed by a psychiatrist for 64.6% of the individuals with olanzapine being the most frequently prescribed antipsychotic at initiation (34.3%). Among those who had initiated
Discussion
In this cohort of individuals with schizophrenia who were new antipsychotic users, visiting multiple pharmacies was frequent; 54.1% of individuals claimed their prescribed drugs in more than one pharmacy over a one-year period. Individuals who visited four different pharmacies or more (approximately 10% of the cohort) were significantly more likely to discontinue their antipsychotics within the two years after initiation and more likely to be exposed to an antipsychotic for <80% of the days.
Conclusion
Results from our study have implications for healthcare teams and researchers. These results could be used to sensitize healthcare teams to the fact that individuals having very erratic pharmacy visiting patterns are also more likely to be non-persistent and have suboptimal implementation. Efforts should be made to identify individuals whose pharmacy-visiting patterns are irregular and put in place strategies to ensure adequate medication follow-up. In addition, healthcare teams may present
Funding
This work was supported by the Laval University Chair on Adherence to Treatments. The Chair on Adherence to Treatments was funded through unrestricted grants from AstraZeneca Canada, Merck Canada, Pfizer Canada, Sanofi Canada and the Prends soin de toi program. At time of the study, F. Zongo had a post-doctoral research scholar award from the Programme canadien de bourses de la Francophonie; S. Lauzier has a research scholar award from the Fonds de recherche du Québec – Santé in partnership
Authors' disclosures of potential conflicts of interest
J. Moisan, J.-P. Grégoire and S. Lauzier, are researchers at the Laval University Chair on Adherence to Treatments. The Chair on Adherence to Treatments was funded through unrestricted grants from AstraZeneca Canada, Merck Canada, Pfizer Canada, Sanofi Canada and the Prends soin de toi program. Other authors have indicated no potential conflicts of interest.
Previous presentation of the data
Brief highlights from this study were presented at the 27th International Conference on Pharmacoepidemiology and Therapeutic Risk, Chicago, 14–17 August 2011 (Lauzier S, Moisan J, Grégoire J-P. Pharmacy Loyalty and Compliance with Antipsychotics, oral podium presentation).
Acknowledgments
The authors are thankful to Eric Demers for the statistical analysis and to Norma Perez for her contribution to bibliography research.
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