1. Impact of an antidepressant adherence program in a managed care organization Kara Zivin Bambauer, PhD Stephen Soumerai, ScD Alyce Adams, PhD Fang Zhang, PhD Rick Weisblatt, PhD Neil Minkoff, MD Andrea Grande, RPh Dennis Ross-Degnan, ScD Harvard Pilgrim Health Care and Harvard Medical School

2. Background The burden of depression is substantial Effective medications are available to treat depression Non-adherence to antidepressants remains a substantial problem Harvard Pilgrim Health Care (HPHC) sought to improve quality of care for depression using available electronic data

3. Objectives To evaluate the effectiveness of providing faxed feedback to physicians regarding patient refill behavior Does the proportion of patients who are potentially non-adherent to treatment decrease after the policy? Does the proportion of days within a treatment episode without antidepressant coverage decrease after the policy?

4. Content of Fax Introduction: This is a clinical reminder to assist physicians who are treating patients for Major Depressive Disorder (MDD) Explanation: There are 3 quality of care measures for depression treatment Summary: information on antidepressant compliance Symptoms usually remit in 4-6 weeks Therapy should be continued for 6 months Only 40% of patients of patients adhere to antidepressant treatment Closing: Your patient (insert name) has gone more than 10 days without antidepressant treatment (medication name, dose, quantity)

5. Antidepressant Compliance Program (ACP) Definitions Adherent: antidepressant prescription refilled within 10 days of an expected refill If not, a fax is sent to the prescribing physician Potentially non-adherent: antidepressant prescription refilled more than 10 days and less than 30 days after an expected refill Failure: antidepressant prescription not refilled within 30 days of an expected refill

6. Assumptions Underlying ACP The prescribing physician receives the fax The physician makes contact with the patient A physician-patient conversation occurs that effectively deals with the reasons for patient non-adherence The patient subsequently refills the antidepressant prescription in a timely manner

7. Inclusion Criteria All HPHC members were eligible All types of providers were included Each patient needed to be enrolled for 6 months before and 6 months after first antidepressant use Patients were included who used a select subset of antidepressants usually indicated for treatment of depression New users of antidepressants (no use in previous 100 days) First episode of antidepressant treatment for each person Age 18

8. Timeline

9. Methods Interrupted time-series (ITS) analysis using SAS PROC AUTOREG Used to evaluate rates of change in adherence due to the ACP Look at slope and level changes ITS is one of the strongest quasi-experimental designs for studying policy changes

10. Characteristics of Study Participants (N=13,128) Mean age (sd): 42 (11) Gender: 69% female Policy Variables Adherent: 18% Potentially non-adherent: 29% Failure: 53% No significant differences in pre-policy and post-policy patients

11. Percent Adherence Failures Percent of Non-Adherent Patients Who Proceed to Adherence Failure Pre-ACP period First year of ACP Phase-in period

12. Percent Treatment Days Uncovered Mean Percent of Treatment Days Not Covered Pre-ACP period First year of ACP

13. Limitations and Implications Electronic reminder systems, while popular, may not improve patient adherence Success of such interventions requires a complex chain of events to occur We cannot determine from electronic data whether communication between physicians and patients addresses reasons for patient non-adherence Stand alone interventions targeting adherence are not successful

14. Conclusions The ACP was not successful at increasing antidepressant adherence rates in HPHC members Additional research should re-examine assumptions underlying the ACP to identify ways to improve future antidepressant adherence interventions Effectiveness of electronic interventions should be carefully evaluated before widespread implementation