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Background Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults. Objectives To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities. Methods This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected. Results In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR) = 0.99 (95% confidence interval (CI) = 0.994–0.995), male sex (OR = 0.93, 95% CI = 0.926–0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR = 0.64, 95% CI = 0.626–0.650), having a hospitalization (OR = 0.87, 95% CI = 0.839–0.893) or emergency department visit (OR = 0.67, 95% CI = 0.658–0.686), and number of comorbidities (OR = 0.90, 95% CI = 0.896–0.905). Conclusions CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.

Background Medication nonadherence remains a significant public health problem, and efforts to improve adherence have shown only limited impact. The tailoring of messages has become a popular method of developing communication to influence specific health-related behaviors but the development and impact of tailored text messages on medication use is poorly understood. Objectives The aim of this paper is to describe an approach to developing theory-based tailored messages for delivery via mobile phone to improve medication adherence among patients with diabetes. Methods Kreuter's five-step tailoring process was followed to create tailored messages for mobile phone delivery. Two focus group sessions, using input from 11 people, and expert review of message content were used to adapt the survey instrument on which the messages were tailored and edit the developed messages for the target population. Results and conclusions Following established tailoring methods a library of 168 theory-driven and 128 medication-specific tailored messages were developed and formatted for automated delivery to mobile phones. Concepts from the Health Belief Model and Self-Determination Theory were used to craft the messages and an algorithm was applied to determine the order and timing of messages with the aim of progressively influencing disease and treatment-related beliefs driving adherence to diabetes medication. The process described may be applied to future investigations aiming to improve medication adherence in patients with diabetes and the effectiveness of the current messages will be tested in a planned analysis.

Background Concern belief in medication is a construct that may characterize patients' attitude toward managing medicines, and this could change with time. Understanding the factors that would impact a change in concern beliefs would be helpful in interventions that could reframe patients' perceptions about their medicines. Objectives To examine if patient concern beliefs in medications change over time, assess the characteristics of individuals whose beliefs change, and determine what factors might impact a change in patient beliefs. Methods Secondary data analysis using 2 longitudinal studies. The first study was an Internet-based survey of Medicare enrollees pre-post Medicare Part D. The second study was a randomized controlled trial evaluating a medication management intervention among adults with physical limitations. Respondents were classified as those whose beliefs remained stable and those whose beliefs increased and decreased over 2 separate periods. Chi-square analysis examined significant differences across the groups. Multiple linear regressions examined factors that influence changes in patient beliefs. Results Among older adults, there were differences in perceived health status ( χ 2 =26.05, P =.001), number of pharmacies used ( χ 2 =17.41, P =.008), and number of medicines used after the start of Medicare Part D. There were no significant differences among adults with physical limitations. Among older adults, having an increased number of medicines over time and reporting a self-reported adverse effect to a physician were positively associated with an increase in concern beliefs in medication. Having an increase in adherence was associated with a decrease in concern beliefs over time. Conclusion Concern beliefs in medications may contribute independent information about individuals' response to drug programs and policies. Outcomes of medication use may influence patient anxieties about medicines. The instability of patient concerns in medications that occurs with prescription drug coverage changes, and the emergence of adverse outcomes of medication use may provide insight into the development of individualized interventions.

Background Incentive-based prescription drug cost sharing can encourage seniors to use generic medications. Little information exists about prescription drug cost sharing and generic use in employer-sponsored plans after the implementation of Medicare Part D. Objectives To compare prescription drug cost sharing across prescription insurance type for Medicare beneficiaries after Medicare Part D, to assess the impact of that cost sharing on the number of medications used, and to examine how generic utilization rates differ before and after Medicare Part D and across the type of insurance. Methods This longitudinal study of Medicare beneficiaries aged 65 years and older used Web-based surveys administered in 2005 and 2007 by Harris Interactive ® to collect information on prescription drug coverage and medication use. Co-payment plans were categorized as low, medium, or high co-payment plans. Multiple regression was used to assess the impact of co-payment rank on the number of prescription drugs. t -Tests and analysis of variance were used to compare generic use over time and between coverage types. Results One thousand two hundred twenty and 1024 respondents completed the baseline and follow-up surveys, respectively. Among 3-tier co-payment plans, brand drug co-payments were higher for Part D plans ($26 for preferred brand and $55 for nonpreferred brand) than employer-based plans ($20 for preferred brand and $39 for nonpreferred brand). Co-payment was not a significant predictor for the number of prescription drugs. Generic use was lowest among beneficiaries in employer plans both before and after Part D. In 2007, generic use among beneficiaries with Part D was not significantly different from the generic use for beneficiaries with no drug coverage. Conclusions Medicare beneficiaries in Part D had higher cost sharing amounts than those with employer coverage, but higher cost sharing was not significantly linked to lower prescription use. Generic use for Part D beneficiaries was higher than that for beneficiaries with employer coverage but the same as that for beneficiaries without drug coverage.

Background A major drawback in the medication adherence literature today is the absence of a gold standard for measuring medication adherence. Objective measures of nonadherence such as prescription claims and pill count, while quantifying nonadherence, do not provide the reasons for nonadherence, hence making it difficult to develop intervention strategies. Self-reported measures are helpful to determine reasons for nonadherence; however, widely used self-reported measures such as the Morisky scale are restricted to only few potential reasons. Objectives The objective of this study was to develop a new scale to measure self-reported nonadherence and to compare it with the existing Morisky scale. Methods A cross-sectional study of adult U.S. population on cholesterol-lowering and asthma maintenance medications was used. Data on nonadherence were collected using (1) the newly developed Medication Adherence Reasons Scale (MARS), (2) Morisky scale, and (3) an objective self-reported measure. Results A total of 840 responses were collected. Factor analysis of MARS resulted in 5 subscales in cholesterol-lowering medications and 3 subscales in asthma maintenance medications. The level of agreement between both scales in identifying adherents and nonadherents as measured by kappa coefficient was 0.381 in cholesterol-lowering medications and 0.545 in asthma medications. MARS was able to identify various other significant reasons for nonadherence than that identified by the Morisky scale. Conclusion A new subjective measure of medication nonadherence based on the frequently reported reasons of nonadherence was developed, and it showed adequate reliability when compared with the Morisky scale to warrant future study.

Background Adverse drug events (ADEs) are generally preceded by symptoms reported by patients, and understanding who reports symptoms is important in understanding ADEs. Objectives The objectives of this study were to (1) determine the prevalence of symptomatology experienced, recalled, and reported to physicians (2) quantify the extent of attribution of recalled symptoms to medicines, and (3) predict factors associated with the reporting of recalled symptoms. Methods This was an Internet-based survey administered by Harris Interactive ® . Data collected and included in the analysis were symptoms experienced, symptom attribution to medicines, number of medicines, concern and necessity beliefs in medicines, self-rated health, number of physician visits, hospitalizations and emergency room visits in the past 6 months, whether patients had to pay part of their prescription costs, number of pharmacies, self-reported medication adherence, and sociodemographics. A descriptive analysis of sociodemographic and clinical/behavioral characteristics was completed, the frequency distribution of symptoms and their attribution to medication was obtained, and independent factors that predicted who was likely to report symptoms to physicians, using a multiple logistic regression analysis, were identified. Results Sixty-two percent (n=751) reported having at least 1 of 10 symptoms in the past month. Of the 1220 Medicare enrollees, 6.0-31.1% experienced varied specific symptoms. Of those who recalled they had experienced a particular symptom, 11.7-48.8% thought the symptoms were related to the medicine they were taking. Reporting symptoms to physicians was positively related to concern beliefs, seeing physicians ≥ 2 times in the past 6 months, perceiving symptom experienced was due to medicines, using more than 3 pharmacies, and not having to pay part of prescription costs. Conclusions Assessing beliefs in medications may help to identify unreported symptoms and subsequent ADEs. In addition, symptom reporting to physicians and other health professionals should be encouraged so that preventable ADEs are detected.

Background Medicare Part D took effect in January 2006 with requirements for prescription drug plans to provide medication therapy management (MTM) services to targeted Medicare beneficiaries. The use of Medicare Part D MTM is voluntary by Medicare beneficiaries and no research evidence is available that can inform policy makers of the beneficiary and provider access-level circumstances under which older adults are more likely to demand MTM-like services. Objective The objective of this study was to describe the effects of the characteristics of older adults and their provider access on the demand for MTM services using data from a unique pre-Medicare Part D program for Medicare-eligible older adults in Iowa. Methods A retrospective cohort study using enrollment, claims, and provider data from the Iowa Priority Prescription Savings (IP) Program. The dependent variable was whether the IP members obtained the MTM service offered by the program. Logistic regression was used to assess whether IP member characteristics and their provider access affected the probability of the IP member to obtain the MTM service. Results Demand for the service varied with IP member age, gender, monthly number of drugs taken, monthly prescription drug spending, self-reported health status, having alternative insurance, and seeing multiple physicians. Increased access to pharmacies promoting the service increased IP member demand. Conclusion The demand for MTM-like services varies with the characteristics of older adults and their access to providers that promote the service. Older adults who view themselves as sicker and those with more complex medication regimens appear more likely to demand a service, suggesting that the benefits of the service are either more important or more recognizable to them. However, it appears that older adults require contact with pharmacies that promote MTM services to recognize this value.

Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. As part of the coverage, medication therapy management services (MTMS) are mandated for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level.To predict the behavioral intention of pharmacists to provide Medicare medication therapy management services (MTMS) using the theory of planned behavior (TPB) and to determine the relationship between pharmacists' characteristics and intention to provide MTMS.The population for this cross-sectional descriptive study consisted of all community pharmacists in Iowa. Data collection occurred through a self-administered anonymous mail survey. Two surveys each were mailed to 500 pharmacies selected through a stratified random sample, 1 survey for the pharmacy manager and 1 survey for a staff pharmacist if applicable. Descriptive statistics and scale reliability were calculated for each of the 4 TPB scales (attitude, subjective norm, perceived behavioral control, and intention). Linear regression was used to predict intent as a function of the other 3 TPB factors, demographic factors, experience, and type of pharmacy.Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. Pharmacists' intent to provide MTMS was generally positive but varied in strength with a mean score of 22.47 (+/-4.00) and a range of 7-30. Pharmacists mostly agreed that they had appropriate training to provide MTMS but lacked time and support. The linear regression analysis found the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of intent (P.05). Pharmacists with stronger intent to provide MTMS were those who felt they had more control over providing MTMS, felt their peers approved of the provision of MTMS, and had a positive attitude about providing MTMS. Type of pharmacy and pharmacist demographic variables were not significant predictors of intent to provide MTMS.Pharmacists showed generally positive intent to provide MTMS. Perceived behavioral control, subjective norm, and attitude were significant predictors of intent (P.05). Strategies to help pharmacists provide MTMS should focus on finding time and support to provide MTMS rather than individual educational needs.