Direct Pharmacist Interventions Confront Health Disparities in Underserved Areas

A session at the 2021 Pharmacy Quality Alliance Meeting, which is being held virtually from May 11-17, explored how Walgreens pharmacies are employing advanced analytics and direct interventions to address health disparities in disadvantaged neighborhoods.

The past year has shed light on numerous injustices, causing many of us to reexamine our approach and influence on healthy equity, according to Michael Taitel, PhD, senior director of health analytics, research, and reporting at Walgreens.

“In many socially vulnerable communities, pharmacies are beacons of light,” said Taitel. “We may be the only source of groceries, over-the-counter medication, and other necessities in those communities.”

According to Taitel, pharmacists can proactively address health disparities through direct intervention strategies that target and build relationships with at-risk patients.

In the session, Taitel and co-presenter Stacy Emmons, PharmD, director of patient outcomes performance at Walgreens, discussed Walgreens’ recent operational response to addressing social determinants of health in underserved communities and the results of the new initiatives. Their findings focused specifically on medication adherence and outreach programs for asthma and diabetes.

Health Disparities in Chicago

Taitel presented data on the stark health disparities demonstrated across different areas of Chicago, Illinois.

Looking at pediatric asthma emergency room (ER) visits, for example, Taitel showed 142.8 per 10,000 visits in lower-income areas versus 97 per 10,000 visits in higher-income areas. Similar disparities are also seen across diabetes, influenza and pneumonia cohorts.

“Most disturbing, we see a big difference in diabetes-related deaths per 100,000 with 74 deaths per 100,000 in lower-income communities compared with 49.7 in higher-income,” Taitel said.

Moreover, based on Walgreens’ pharmacy data tracking medication adherence, individuals in lower-income areas such as the south and west sides of Chicago demonstrated lower adherence to diabetes, hypertension, and statin medications compared with the north side.

“It’s showing us that where someone lives also makes a difference in their adherence,” Taitel said. These factors tie into social determinants of health that lead to adverse outcomes for social and ethnic minority groups. Other factors, including discrimination, education, occupation, and health care access and utilization, all play a role in health equity.

Walgreens’ Response

Taitel explained that Walgreens incorporated the following strategies to ensure continuity of access and care during times of disruption in vulnerable communities.

• Activated mobile pharmacies in heavily affected communities: 2 in Chicago and 4 in Minneapolis, Minnesota 
• Sent automated notifications about store closures and re-openings
• Conducted outreach for patients with upcoming refills
• Telephoned patients who were late to refill or delayed in pickup
• Contacted providers to discuss care continuity

Other methods, such as distributing communications materials, using digital features, and offering prescription delivery services can also help create additional access for individuals when their usual site of care is disrupted.

Walgreens also tested the implementation of specifically targeted interventions in these areas, setting up a “health equity incubator.”

“Starting in Chicago, we had 1 store [that] we then matched with a control store to develop specifically targeted interventions above and beyond the ones I’ve already mentioned,” Taitel said. Based on the success of the 1 store, Walgreens then expanded to 16 stores in Chicago.

“Eventually, as we continue to see success in this incubator, we will take [what we learned] and expand it nationally,” Taitel said.

Strategies and Results

Prescription abandonment is one factor that contributes to medication adherence, according to Emmons. The most likely contributing factors to prescription abandonment are thought to be cost, lack of transportation, and forgetting to take the medication. These are also barriers to achieving overall health equity.

“We work to implement services and strategies that will reduce delayed prescription pickup,” she said.

Walgreens initiated a delayed pickup patient journey strategy to address this issue. The interventions involve refill reminders and a delayed pick-up list, which enables pharmacy team members to reach out to patients and provide options for tools or solutions, such as prescription delivery, that can help ease accessibility.

“In these 16 locations, we have found that having direct delayed pick-up conversations encouraging patients to utilize digital and delivery options improve the rate of prescription abandonment,” Emmons said. According to her, these interventions nearly doubled the percentage of delayed pick-up prescriptions sold.

Another intervention being studied is a pediatric asthma outreach program. The strategy involves the pediatric patient, their caregiver, and the pharmacist, and is designed to enhance provider-patient relationships and drive adherence.

The pharmacy team enables the latest clinical guidelines, newly prescribed patient consultations, and high-risk asthma consultations to drive better clinical outcomes. Emmons explained that, through high-touch asthma consultations, pharmacists provide education on the disease state and the medication, as well as proper inhaler technique. Pharmacists also distribute resources to patients as needed; this includes an asthma action plan, peak flow log for inhalers, and pediatric asthma activity handouts.

As a result, prescription refill rates improved significantly for patients in the pediatric asthma program compared with those in the control group, Simmons said.

Test stores also implemented a diabetes outreach program using predictive analytic models to target patients based on their historical adherence behaviors. Pharmacists use clinical conversations to address patients who have been targeted as potentially requiring interventions. “We developed holistic interventions to remove adherence barriers and close gaps to care,” Taitel said.

These gaps can include patients who are not taking statins, those who have not received their flu or pneumonia vaccinations, and those who are not testing their glycated hemoglobin.

“Our pharmacists also document those gaps and document the results of those conversations, which then can be fed back into our predictive models,” Taitel explained.

According to Taitel, they looked at the percent of diabetes prescriptions being refilled within 2 weeks of the due date. “We see that as a more proactive and leading indicator of adherence,” he said.

The interventions yielded significant improvement in 3 indicators: adherence, statin use, and flu vaccinations. In the intervention period, test stores improved 2.1% from the preperiod, while the control group stores did not improve during the same period.

Reference

1. Emmons S, Taitel M. Pharmacies pursuing health equity: Addressing disparities through direct pharmacist intervention. 2021 Pharmacy Quality Alliance Annual Meeting; May 11-17, 2021; virtual. Accessed May 12, 2021.