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Evaluating yourclinical programs withprescription claim recordsMichael Crowe

One o the biggest challenges to pharmacies has always been limitedaccess to patient inormation 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

o inormation not held by our medical colleagues: prescription claim

records. There is much that pharmacists can do with this rich data set.

Calculating the medicationpossession ratioMedication adherence, as measuredby medication possession ratio (MPR),can easily be calculated rom the datain dispensing system report. The data

points needed are the unique patientidentier, drug name, days supplied,and date o ll. Using these data, youcan calculate MPR using the ormulain Figure 1. The resulting MPR usu-ally ranges rom 0 to 1, with 1 corre-sponding to 100% adherence. It is pos-sible or MPR to exceed 1; this case isdiscussed below.

For a single patient, MPR can bemanually calculated quickly and eas-ily. But or a large patient population,manual calculations are not practical.Instead, you can use Microsot Excelunctions such as sort, remove dupli-cates, VLOOKUP, and pivot tables.You can learn more about these unc-

tions on the Microsot Oce onlinehelp page (http://oce.microsot.

com/en-us/support/). Figure 1 ex-plains the steps involved in calculat-ing MPR within a spreadsheet, whichcan be applied to a large patient popu-lation.

Make the most of your dataWhile prescription claim recordsare objective measures o adherencewhich are relatively inexpensive toobtain, they do have some shortcom-ings. First and oremost, dispensing amedication does not necessarily entail

its use. Also, MPR may be overstatedor understated early in therapy dueto dose adjustments (e.g., titrations).Patients lling their prescriptions atmore than one pharmacy will havelow MPR values due to incompleteclaim records. Last, because dayssupply is manually entered by phar-macy sta and can require adjustmentdue to third party payer regulations,it may not refect the true number odays supply o the prescription.

Given these shortcomings, thereare a variety o ways to improve theaccuracy o your results. First, i yourdispensing system can report a pick-up or delivery date instead o lldate, the MPR calculation will betterrefect the patients actual possessiono a medication. Another adjustmentis to include a washout period. To dothis, run your report beginning withll dates at least 3 months prior tothe timerame o interest. Then, a-ter completing steps one through six

in Figure 1, eliminate patients with arst ll occurring in that lead-in pe-

riod. This will help ensure that yourpatient population includes only pa-tients who started therapy in the time-rame o interest. Similarly, i you areevaluating adherence or patients ona medication with a predened dura-tion o therapy (e.g., teriparatide [For-teoEli Lilly], hepatitis C regimens),you can use an extended window otime and eliminate patients with a lastll date occurring in the last 3 months.This will generally limit your popula-tion to patients who have completedor discontinued their regimen.

It is usually recommended to re-

move patients with only one ll. Bydenition, the MPR or these patientsis always 1, and including these datawill art icially infate the overall MPRor your patient population. MPR orthe patient population can also be ex-aggerated by patients with repetitive

early rells. A solution or this is tocap MPRs at 1. To do so, create a col-umn within the original worksheet(column K in our Figure 1) and enterthe ormula =IF(J2>1, 1, J2) withoutthe quotation marks. This will reduceall values greater than 1 to 1, thuseliminating overstated MPRs.

Beyond MPROnce MPR has been calculated, theduration o therapy is easyit is sim-ply equal to the denominator o theMPR equation: last ll date minus rstll date plus days supply at last ll.To ensure that this calculation refectsthe true duration o therapy, utilize awashout period as described above.

With little additional inormation,you can use similar techniques to de-termine other patient and populationcharacteristics, such as proportion opatients with a dose change or numbero patients receiving a specic adjuncttherapy. This could be useul with, or

example, patients with hepatitis C vi-rus (HCV) who have a multidrug regi-

Prescription claim records

data can be utilized to calcu-

late valuable metrics for phar-

macy efforts such as medica-

tion therapy management andadherence programs.

Spreadsheet applications

such as Microsoft Excel make

calculations feasible for large

patient populations.

We do have access to one veryvaluable piece of informationnot held by our medical

colleagues.

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men that requires high levels o ad-herence or a specic period o timedictated by genotype, response, andtherapy tolerance. Ribavirin, one othe agents in this regimen, is knownto cause hematologic adverse eectswhich oten lead to dose reductionsor the initiation o erythropoieticagents.

A pharmacy may want to providean adverse eect management pro-gram to patients with HCV to helpthem remain adherent to their ther-apy. Using the steps outlined above,this pharmacy can evaluate patientadherence and duration o therapy,two important measures o this pro-grams eectiveness. Another valu-able metric is the proportion o pa-tients who have had a dose reductionor are also prescribed epoetin ala.

To determine dose reductions,generate a report or patients using

ribavirin similar to the report de-scribed above or MPR calculations,but include the ribavirin dose as aseparate column. Note that in this ex-ample, the totaly daily dose must beused; this may need to be calculatedin a new column using tablet strengthand quantity dispensed.

Next create a pivot table includingall o the columns, using patient ID orrow label and dose twice or valueone with the value eld settings set tomaximum and one to minimum. Thedierence between these columns isthe dose reduction. A number o ad-ditional metrics can be drawn romthis calculation, including proportiono patients receiving a dose reductionand average dose reduction.

To evaluate the use o epoetin alain conjunction with dose reductions,

generate an epoetin ala dispense re-port and then use Excels VLOOKUP

unction to combine epoetin ala datawith the ribavirin report. This time,create the pivot table using the addedadjunct therapy column as a lter tocompare dose reductions with the useo epoetin ala.

This is just the beginning o whata pharmacy can do with its prescrip-tion claim records. With a little timeand motivation, pharmacists can divemuch deeper into these data to calcu-late metrics such as median gap andcorrelation between select patientcharacteristics and rell habits. Manydispensing systems even allow usersto assign patients to certain groups,such as disease states or programs,which could also help stratiying theresults o data analyses.

Michael Crowe, PharmD, FMPA

Clinical Technology ManagerDiplomat Specialty Pharmacy

Figure 1. Calculating a medication prescription ratio in Microsoft Excel

Patient ID Drug Name

Days

Supply Fill Date

Total Days

Supply Last Fill Date First Fill Date

Last Fill

DaysSupply # Fills MPR

M338C123 FORTEO 28 02/12/2013

M338C123 FORTEO 28 03/07/2013 ? ? ? ? ? ?

M338C123 FORTEO 28 04/04/2013 ? ? ? ? ? ?

M338C123 FORTEO 28 05/11/2013 ? ? ? ? ? ?

Patient ID Drug NameDays

SupplyFill Date

Total Days

SupplyLast Fill Date First Fill Date

Last Fill

DaysSupply

# Fills MPR

M338C123 FORTEO 28 02/12/2013 112 05/11/2013 02/12/2013 28 4 0.9655

u Create a pivot table that analyzes all data in columns Ato C of the original worksheet. Use patient ID as the rowlabel and days supply as the value. Adjust the value field

setting to Sum, thus returning the sum of days supply foreach 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 originalworksheet into a new worksheet. Sort the contents first bypatient ID, then by fill date from newest to oldest. Use the

remove duplicates function to remove repeated patientrecords. 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 eachpatient ID.

After following steps 1 to 6 below, duplicate patients can be removed.

w Repeat Step 2, but this time sort from oldest to newest andremove duplicates. The remaining date will be the first f ill date. Usethe VLOOKUP function to add this value to the original worksheet.

x Use the same worksheet created in Step 3 with the VLOOKUPfunction, and instead of using the fill date, use the days supply.

This will be the last fills days supply.

yOptionally, using the pivot table created in Step 1, add drug nameto the value column and ensure that the value field setting is set toCount. 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.

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