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Evaluating your clinical programs with prescription claim records

Michael Crowe

O
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ne of the biggest challenges to pharmacies has always been limited access to patient information such as diagnoses, laboratory values, and physical exam records. While pharmacists may not always have access to patient charts, we do have access to one very valuable piece of information not held by our medical colleagues: prescription claim records. There is much that pharmacists can do with this rich data set. Calculating the medication possession ratio
Medication adherence, as measured by medication possession ratio (MPR), can easily be calculated from the data in dispensing system report. The data com/en-us/support/). Figure 1 explains the steps involved in calculating MPR within a spreadsheet, which can be applied to a large patient population.

riod. This will help ensure that your patient population includes only patients who started therapy in the timeframe of interest. Similarly, if you are evaluating adherence for patients on a medication with a predefined duration of therapy (e.g., teriparatide [ForteoEli Lilly], hepatitis C regimens), you can use an extended window of time and eliminate patients with a last fill date occurring in the last 3 months. This will generally limit your population to patients who have completed or discontinued their regimen. It is usually recommended to re-

We do have access to one very valuable piece of information not held by our medical colleagues.
move patients with only one fill. By definition, the MPR for these patients is always 1, and including these data will artificially inflate the overall MPR for your patient population. MPR for the patient population can also be exaggerated by patients with repetitive early refills. A solution for this is to cap MPRs at 1. To do so, create a column within the original worksheet (column K in our Figure 1) and enter the formula =IF(J2>1, 1, J2) without the quotation marks. This will reduce all values greater than 1 to 1, thus eliminating overstated MPRs.

Make the most of your data


While prescription claim records are objective measures of adherence which are relatively inexpensive to obtain, they do have some shortcomings. First and foremost, dispensing a medication does not necessarily entail its use. Also, MPR may be overstated or understated early in therapy due to dose adjustments (e.g., titrations). Patients filling their prescriptions at more than one pharmacy will have low MPR values due to incomplete claim records. Last, because days supply is manually entered by pharmacy staff and can require adjustment due to third party payer regulations, it may not reflect the true number of days supply of the prescription. Given these shortcomings, there are a variety of ways to improve the accuracy of your results. First, if your dispensing system can report a pickup or delivery date instead of fill date, the MPR calculation will better reflect the patients actual possession of a medication. Another adjustment is to include a washout period. To do this, run your report beginning with fill dates at least 3 months prior to the timeframe of interest. Then, after completing steps one through six in Figure 1, eliminate patients with a first fill occurring in that lead-in pe-

Prescription claim records data can be utilized to calculate valuable metrics for pharmacy efforts such as medication therapy management and adherence programs. Spreadsheet applications such as Microsoft Excel make calculations feasible for large patient populations. points needed are the unique patient identifier, drug name, days supplied, and date of fill. Using these data, you can calculate MPR using the formula in Figure 1. The resulting MPR usually ranges from 0 to 1, with 1 corresponding to 100% adherence. It is possible for MPR to exceed 1; this case is discussed below. For a single patient, MPR can be manually calculated quickly and easily. But for a large patient population, manual calculations are not practical. Instead, you can use Microsoft Excel functions such as sort, remove duplicates, VLOOKUP, and pivot tables. You can learn more about these functions on the Microsoft Office online help page (http://office.microsoft.
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Beyond MPR
Once MPR has been calculated, the duration of therapy is easyit is simply equal to the denominator of the MPR equation: last fill date minus first fill date plus days supply at last fill. To ensure that this calculation reflects the true duration of therapy, utilize a washout period as described above. With little additional information, you can use similar techniques to determine other patient and population characteristics, such as proportion of patients with a dose change or number of patients receiving a specific adjunct therapy. This could be useful with, for example, patients with hepatitis C virus (HCV) who have a multidrug regiwww.pharmacytoday.org

PharmacyToday JULY 2013

Figure 1. Calculating a medication prescription ratio in Microsoft Excel


Last Fill Days Supply

Patient ID

Drug Name

Days Supply

Fill Date

Total Days Supply

Last Fill Date First Fill Date

# Fills

MPR

M338C123 M338C123 M338C123 M338C123

FORTEO FORTEO FORTEO FORTEO

28 28 28 28

02/12/2013 03/07/2013 04/04/2013 05/11/2013

? ? ?

? ? ?

? ? ?

? ? ?

? ? ?

? ? ?

After following steps 1 to 6 below, duplicate patients can be removed. Patient ID Drug Name Days Supply Fill Date Total Days Supply Last Fill Date First Fill Date Last Fill Days Supply # Fills MPR

M338C123

FORTEO

28

02/12/2013

112

05/11/2013

02/12/2013

28

0.9655

u Create a pivot table that analyzes all data in columns A to C of the original worksheet. Use patient ID as the row label and days supply as the value. Adjust the value field setting to Sum, thus returning the sum of days supply for each patient. Then use the VLOOKUP function to match total days supply with each patient in the original worksheet. v Copy and paste the entire contents of the original worksheet into a new worksheet. Sort the contents first by patient ID, then by fill date from newest to oldest. Use the remove duplicates function to remove repeated patient records. Excel removes duplicates that occur after the first duplicate, so the remaining line items for are each patients last fill date. Use the VLOOKUP function to pull this date into the original worksheet, matching it with each patient ID.

w Repeat Step 2, but this time sort from oldest to newest and remove duplicates. The remaining date will be the first fill date. Use the VLOOKUP function to add this value to the original worksheet. x Use the same worksheet created in Step 3 with the VLOOKUP function, and instead of using the fill date, use the days supply. This will be the last fills days supply. y Optionally, using the pivot table created in Step 1, add drug name to the value column and ensure that the value field setting is set to Count. This column can be used to filter out patients based on number of fills received (e.g., one-time fills). Finally, enter the formula for MPR and fill the series so that each patients MPR is calculated. Duplicate patients can now be removed so that each patient has a single MPR.

men that requires high levels of adherence for a specific period of time dictated by genotype, response, and therapy tolerance. Ribavirin, one of the agents in this regimen, is known to cause hematologic adverse effects which often lead to dose reductions or the initiation of erythropoietic agents. A pharmacy may want to provide an adverse effect management program to patients with HCV to help them remain adherent to their therapy. Using the steps outlined above, this pharmacy can evaluate patient adherence and duration of therapy, two important measures of this programs effectiveness. Another valuable metric is the proportion of patients who have had a dose reduction or are also prescribed epoetin alfa. To determine dose reductions, generate a report for patients using
www.pharmacist.com

ribavirin similar to the report described above for MPR calculations, but include the ribavirin dose as a separate column. Note that in this example, the totaly daily dose must be used; this may need to be calculated in a new column using tablet strength and quantity dispensed. Next create a pivot table including all of the columns, using patient ID for row label and dose twice for value one with the value field settings set to maximum and one to minimum. The difference between these columns is the dose reduction. A number of additional metrics can be drawn from this calculation, including proportion of patients receiving a dose reduction and average dose reduction. To evaluate the use of epoetin alfa in conjunction with dose reductions, generate an epoetin alfa dispense report and then use Excels VLOOKUP

function to combine epoetin alfa data with the ribavirin report. This time, create the pivot table using the added adjunct therapy column as a filter to compare dose reductions with the use of epoetin alfa. This is just the beginning of what a pharmacy can do with its prescription claim records. With a little time and motivation, pharmacists can dive much deeper into these data to calculate metrics such as median gap and correlation between select patient characteristics and refill habits. Many dispensing systems even allow users to assign patients to certain groups, such as disease states or programs, which could also help stratifying the results of data analyses.
Michael Crowe, PharmD, FMPA Clinical Technology Manager Diplomat Specialty Pharmacy

JULY 2013

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