Mail order pharmacy patients with diabetes less likely to visit ED than brick-and-mortar pharmacy users

Patients with diabetes who used a mail order pharmacy were less likely to visit the ED than patients who obtained medication in person from a pharmacy, a study found.

Researchers performed a cross-sectional, observational study of 17,217 adult patients with diabetes who belonged to a Kaiser Permanente Northern California patient registry and who were prescribed new antiglycemic, antihypertensive or lipid-lowering medications in 2006. They used multivariate logistic regression to analyze the association between type of pharmacy use and outcomes, which included all-cause and preventable hospitalizations and ED visits.

For patients whose index drug was an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin-receptor blocker (ARB) or a diuretic, the researchers also examined whether there was a lab test within 30 days after the index date. In addition, they looked at serious medication interactions, defined as 2 or more instances of overlapping supply days of contraindicated medications. Results were published online Nov. 20 by the American Journal of Managed Care.

About 34% of patients used a mail order pharmacy; these patients were more likely to be white and of higher socioeconomic status. After stratifying by age, the researchers found that patients younger than 65 who used mail order had fewer ED visits (33.8% vs 40.2%; P<0.001) and fewer preventable ED visits (7.7% vs 9.6%; P<0.01). They also had fewer serum creatinine lab monitoring tests after ACE/ARB or diuretic initiation (41.2% vs 47.2%; P<0.01). In patients who were 65 or older, mail order users also had fewer preventable ED visits (13.4% vs 16.3%; P<0.01) but slightly more instances when the supply of contraindicated medications overlapped (1.1% vs 0.7%; P<0.01).

Limitations of the study include its observational nature, which meant that the researchers couldn't control for differences in the kind of patients who use mail order pharmacies and the kind who don't. Also, the study was conducted in an integrated delivery system, “where patients access prescription medications differently than in many other settings,” the authors noted.

Mail order pharmacy use doesn't appear to be negatively associated with patient safety outcomes on the whole and shouldn't serve as a barrier to care, the researchers concluded. The finding that younger patients who used a mail order pharmacy had lower rates of serum creatinine testing with ACE, ARB or diuretic use suggests in-person pharmacy use may make monitoring medications easier, they noted. As well, the finding that older mail order users are slightly more vulnerable to overlapping contraindicated drugs suggests patients on multiple medications may need extra monitoring, they added.

“System-level interventions to increase mail order pharmacy use may be an important strategy for improving processes and outcomes of care for patients with chronic illness; however, these interventions should use a patient-centered approach that does not increase risk in older patients and others who may be sensitive to primary and preventive care access,” the authors wrote.