Using Behavioral Theories in Pharmacy Services Research

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Using Behavioral Theories in Pharmacy Services
Research

• Karen B. Farris, Ph.D., R.Ph.
• Professor, Division of Pharmaceutical
  Socioeconomics (PSE), College of Pharmacy
• Professor, Community Behavioral Health, College
  of Public Health
• 12.04.08

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Objectives

• Describe medication use in the United States to
  illustrate the breath of research in pharmacy
  services research.
• Describe the theoretical content for our PSE
  graduate program.
• Illustrate pharmacists and patients roles in
  medication use using my research.

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Medication use

• 216.7 billion in 2006, more than 5X the 40
  billion spent in 1990
• Prescription drugs spending was 10 of health
  care expenditures in 2006 (31 hospitals, 21
  physician services)

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Distribution of National Prescription Drug
Expenditures by Source of Payment, 1996-2006
Private Insurance
Public Funds
Consumer Out-of-Pocket Payments
Notes Percentages may not total 100 due to
rounding. Source Kaiser Family Foundation
calculations using NHE data from Centers for
Medicare and Medicaid Services, Office of the
Actuary, National Health Statistics Group, at
http//www.cms.hhs.gov/NationalHealthExpendData/
(see Historical National Health Expenditures by
type of service and source of funds, CY
1960-2006 file nhe2006.zip).
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Relative Contributions of Utilization, Types of
Prescription Drugs Used, and Price to Rising
Prescription Drug Expenditures, 1993-1997 vs.
1997-2002
1993-1997
1997-2002
Source Kaiser Family Foundation and Sonderegger
Research Center analysis using National Health
Expenditures data for prescription drugs from the
Centers for Medicare and Medicaid Services,
Office of the Actuary, National Health Statistics
Group, at http//www.cms.gov/statistics/nhe/histor
ical/, Table 2 price data from IMS Health,
Pharmaceutical Pricing UPDATE, various years and
utilization data from IMS Health, National
Prescription Audit Plus, various years, updated
with data from the IMS Health web site at
http//www.imshealth.com.
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Problems Paying for Prescription Drugs, 2008
How much of a problem is it for you or your
family to pay for prescription medicines that you
need?
A serious problem
Not much of a problem
41
A problem, but not serious
Source USA Today/Kaiser Family
Foundation/Harvard School of Public Health The
Public On Prescription Drugs and Pharmaceutical
Companies (conducted Jan. 3-23, 2008).
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HHS Estimates of Prescription Drug Coverage
Among Medicare Beneficiaries, 2008
No Drug Coverage
Stand-Alone PDPs
4.6million10
Other Creditable Drug Coverage1
11.2million25
4.0million9
Total in Part D Plans 25.4 Million (57)
10.2million23
6.2million14
Dual Eligibles in PDPs
Retiree DrugCoverage2
8.0million18
Medicare Advantage Drug Plans3
Total Number of Beneficiaries 44.2 Million
NOTES Estimates do not sum to 100 due to
rounding. 1Includes Veterans Affairs, Indian
Health Service, state pharmacy assistance
programs, employer plans for active workers,
Medigap, multiple sources, and other sources.
2Includes Retiree Drug Subsidy (RDS) coverage
retiree coverage without RDS and FEHBP and
TRICARE retiree coverage. 3Includes 0.4 million
enrolled in other Medicare health plan types.
PDP Prescription Drug Plan. SOURCE Kaiser
Family Foundation analysis of HHS data, January
31, 2008 (Data as of January 2008).
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Distribution of Covered Workers Facing Different
Cost-Sharing Formulas for Prescription Drug
Benefits, 2000-2008


Distribution is statistically different from
distribution for the previous year shown
(plt.05). No statistical tests are conducted
between 2003 and 2004 or between 2006 and 2007
due to the addition of a new category. Note
Fourth-tier drug cost sharing information was not
obtained prior to 2004. Source Kaiser/HRET
Survey of Employer-Sponsored Health Benefits,
2000-2008.
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Rx drug utilization is

• Costly
• Complex to access
• And we need my economist colleagues in COP to
  sort that out (Brooks, Urmie, Xie Polgreen)
• Not always appropriate
• And we need behavioral folks to work on that
  (Sorofman, Doucette Farris)

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Medication use problems

• Inappropriate prescribing
• Polypharmacy
• Underuse
• Noncompliance (nonadherence)
• Intentional
• Unintentional
• Adverse drug events

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Inappropriate prescribing

• 23.4 and 14 of elderly patients receive a
  medication that is inappropriate, as defined by
  geriatric specialists (8 studies applying Beers
  criteria, (Aparasu Mort, 2000)
• 21.3 elderly patients receive 1 of 33
  medications that are potentially inappropriate
  2.6 receive 1 of 11 to avoid 9.1 receive 1 of
  8 that are rarely appropriate 13.3 receive 1 of
  14 that are often misused (MEPS, Zhan et al.,
  JAMA 2001)
• 21, 48 and 38 in ambulatory, frail elderly
  program and long-term care facility failed Beers
  1997 criteria (Rigler, et al, Ann Pharmacother,
  2005)

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• (Farris, et al, 2005)

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Underuse

• Omission of drug therapy that is indicated for
  treatment or prevention of a disease or condition
• study of community-dwelling elders found that 50
  of 372 vulnerable adults were not prescribed an
  indicated medication, e.g., gastroprotective
  agent for NSAID users, no ACE inhibitor for
  patients with diabetes and proteinuria, and no
  calcium and/or vitamin D for those with
  osteoporosis
• Higashi T, Shekelle PG, Solomon DH, et al. The
  quality of pharmacologic care for vulnerable
  older patients. Ann Intern Med 2004140714720

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Nonadherence

• Up to 40 of patients do not take their
  medications as prescribed
• Do not purchase prescribed medications
• Failure to refill
• Change directions, 50 of 242 ambulatory older
  individual sample..skipping doses (Wallsten,
  1995)
• Intention or unintentional

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Adverse drug events (ADE)

• Injury caused by medication in management of
  patients health and not caused by underlying
  condition
• 35 of ambulatory older adults experience an ADE
  and 29 require health services for it (Hanlon et
  al, 1997)
• 25 of ambulatory older adults experienced an
  ADE 39 were preventable or ameliorable
  (Gandhi, et al. 2003)
• 18 of older adults self-reported an ADE
  (Oladimeji Farris, 2008).

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And what does behavior have to do with this?

• Physician/Prescriber behavior
• Pharmacist behavior
• Client/patient behavior

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What is PSE SAdS ESAS?

• Social Administrative Sciences
• Economics
• Microeconomics
• Social sciences
• Social psychology
• Sociology
• Communication Studies
• Marketing
• Epidemiology
• Statistics

• Applied research including
• Outcomes research
• Health services research
• Marketing research
• Technology assessment

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046263 Models in Patient Behavior and Choice

• This course introduces theoretical models used to
  describe behavior and choice in pharmaceutical
  socioeconomic research, including models from
  economics, health services research, health
  behavior, and clinical decision making.

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Models covered

• Health Belief Model
• Theory of Reasoned Action
• Theory of Planned Behavior
• Theory of Goal-directed Behavior
• Common Sense Model of Illness
• Self-efficacy/Social learning theory
• Trans-theoretical model
• Social support and social networks
• Andersen Behavioral Model
• PRECEDE-PROCEED
• Structure-Process-Outcome
• Basic economic consumer choice model
• Economic models of medical care demand
• The relationship between uncertainty, expected
  utility and medical care demand.
• The effects of insurance on medical care demand
• Clinical decision making and cost-benefit
  analysis
• Cost-Benefit analysis and discrete demand
  economic modeling

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Research foci

• Role and impact of community pharmacists on
  patients' medication use
• Older adults and medication use

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Role and impact of community pharmacists on
patients' medication use
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Theory of Goal-Oriented Behavior (Bagozzi)
Theory of Planned Behavior (Ajzen)
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• Karen B. Farris and Duane M. Kirking. Predicting
  community pharmacists' choice among means to
  prevent and correct clinically significant
  drug-therapy problems. J Soc Admin Pharm
  19981569-82

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• Causal model of pharmacists behavior , Karen B.
  Farris, Donald P. Schopflocher. Between
  intention and behavior an application of
  community pharmacists assessment of
  pharmaceutical care. Soc Sci Med 19994955-66

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Structure-Process-Outcome
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Team Performance Involving Pharmacists
EExcellent, VGVery good, GGood, FFair, PPoor
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Some medication use changes

• Numbers of medications ? in intervention group
  with 256 recommendations increase dose (34),
  add another non-diuretic antihypertensive (30)
  and add a thiazide diuretic (17) as primary
  changes
• BP was controlled in 89 of intervention patients
  and in 54.5 of control patients (odds ratio 6.7
  (95 CI 2.9-15.4, plt0.001).
• Healthcare use showed ? trends for physician
  visits, ER visits and hospital admissions, while
  maintaining baseline health status over the
  winter season.
• Self-reported compliance ? at 3 months (p0.004)
  and was maintained at 6 months (p0.01).
• Patients with a high risk drug ? for those who
  received PCM vs not receiving PCM.
• Medication appropriateness index improved.

Improved team performance
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Stages of Change
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Older adults and medication use
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Self-care agency (Orem)
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Self-regulation (Leventhal Horne)
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Concern beliefs in medicines (Horne)

• Summative scale using 5-Likert scale
• I sometimes worry about the long term effects of
  my medicines.
• Having to take my medicines worries me.
• I sometimes worry about becoming too dependent
  on my medicines.
• My medicines disrupt my life.
• My medicines are a mystery to me.
• Ranges from 5-25 reliability 0.65-0.86 and
  construct validity has been established

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Frequency of reasons accounting for non-adherence
to cholesterol-lowering medicines (John
Farris, in process)

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Frequency of reasons accounting for non-adherence
to asthma maintenance medicines (John
Farris, in process)
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Self reported symptoms in the past month among
Medicare enrollees (n1220) (Oladimeji Farris,
2008, forthcoming)
a. Denominator in column 2 is 1220. b.
Denominator in columns 3 and 4 is frequency of
experiencing that specific symptom
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Psuedo-participatory research

• Diffusion of innovation
• Social marketing materials
• Practice change to increase counseling
• Collaborative practice agreements

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Community Pharmacists Roles in Improving
Reproductive Health in Iowa

• Pharmacists are accessible healthcare providers.
• Pharmacies provide important access to
  contraceptives.
• Pharmacies and pharmacists have not made the most
  of their patient-oriented and public health
  roles.

We intend to change pharmacists roles in
reproductive health to impact unintended
pregnancies in Iowa.
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To create this change, we will...

• Understand the role of community pharmacists in
  reproductive health, particularly for women age
  18-30 years old.
• Design and implement a county-level,
  pharmacy-based intervention to impact womens
  reproductive health that can be communicated to
  other pharmacies.
• Evaluate the impact of a county-level,
  pharmacy-based reproductive health intervention.

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Lessons Useful to this Study

• KNOW where practice is.
• ASK pharmacists, but push practice.
• PILOT, pilot, pilot interventions in actual
  practice.
• Offer RANGE of interventions and document.
• Dont re-invent the WHEEL.
• STAY in touch with participants.

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Summary

• Use numerous behavioral theories, with two foci
  (1) translating what works into practice on
  pharmacy practice and (2) understanding patients
  medication use attitudes and behaviors

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Contextual factors such as personal norms e.g.
social and cultural norms
2a
5a
Perceptions of treatment e.g. beliefs about
medicines
3a
4a
1a
Illness representation
Coping procedure
Appraisal
Health threat e.g. symptoms
Emotional response to symptoms/illness
Coping procedure
Appraisal
1b
4b
5b
3b
Emotional responses to treatment (medication)
e.g. worry, fear (seen in concern beliefs in
medicines)
2b