Background: Mail order pharmacies (MOP) are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or greater medication adherence than local pharmacy (LP) use. Medication adherence is associated with improved outcomes, including reduced cardiovascular events, health care costs, and mortality. We are unaware of any studies that have evaluated the association of MOP use with medication adherence among stroke patients. Objective: To investigate whether stroke patients who use MOPs were more likely to have good medication adherence than those who used LPs and whether adherence was associated with 90 day hospital re-admission after stroke. Methods: We conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals who received a new anticoagulant, antiplatelet, antiglycemic, antihypertensive, and/or lipid-lowering medication between 01/JAN/2007 and 30/JUL/2016. We compared adherence between MOP users (at least 66% of refills by mail) and LP users (all refills in person). Adherence was calculated by using the Continuous Medication Gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication is divided by the number of days in the study window for that patient. A CMG adherence score of 0 meant that the patient had no overall gaps in their medications (perfect adherence), a negative number meant that the patient had more medication than days, and a positive number meant that the patient did not have enough medication for the days they should be taking their medication (poor adherence). Results: A total of 44,658 eligible patients refilled an index medication. Of these, 13,676 in the LP and 6,907 in MOP group met inclusion criteria. CMG adherence was 0.28 in the LP group and 0.11 in the MOP group ( p < 0.001). At 90-days there were 893 hospital readmissions for the LP group and 375 for the MOP group for a rate of 0.073 vs. 0.058 (p < 0.001). Conclusions: Stroke patients who obtain medication by mail are more likely to have good adherence, and less likely to be readmitted than those who obtain medications from their local pharmacies.
Introduction: Depression is common after ischemic stroke (IS). Stroke survivors who are depressed are at greater risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. However, how depression leads to poor IS outcomes is unclear and few studies have shown an association between depression after stroke and healthcare use. Objective: To evaluate the impact of depression on medication adherence after stroke. Methods: We analyzed the multicenter database comprising information drawn from electronic medical records and pharmacy records (Healthconnect, POINT). All ischemic stroke patients presenting to one of 11 medical centers within a health maintenance organization in California between January 1, 2007 and June 30, 2015 with at least 2 medication fills for a stroke prevention medication and six months of information were evaluated. Adherence was calculated for antihypertensive, hypoglycemic, and lipid lowering medications, but not for antiplatelet or anticoagulant medications as the latter may be obtained over the counter, or with variable daily dosing, which would bias adherence calculations. Adherence was calculated by using the continuous medication gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication was divided by the number of days in the study window for that patient. Results: There were 9933 patients with ischemic stroke during the study period. Of these, 2019 had a diagnosis of depression made after the index stroke. Among the non-clinically depressed patients the CMG adherence was 0.22 (Standard Deviation +/- 0.29), while among clinically depressed patients it was 0.28 (SD +/-0.32, p<0.0001). Conclusions: Ischemic stroke survivors diagnosed with depression after an index stroke are overall 26% less likely to be adherent to key secondary prevention drugs than their non-depressant counterparts. Poor medication adherence among depressed stroke patients may be an important contributor to their relatively poorer clinical outcomes.
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