Some patients halted drugs for chronic conditions during pandemic

Daily allotment of prescription drugs
Daily allotment of prescription drugs

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Most US patients saw an increase in days of supply (DOS) for medication for chronic conditions during the pandemic, but prescription data still showed an increased likelihood of drug discontinuation, according to a study published last week in PLOS One.

The researchers chose an example drug with available generics from six therapeutics classes less likely to be affected by the COVID-19 pandemic: hormonal contraception, immunosuppression, serotonin regulation, and drugs to address attention deficit hyperactivity disorder (ADHD) and psychoses. They determined that patients had discontinued a drug if the DOS were not sufficient to cover a given month.

"We heard all this news about how the rules were relaxing around refills [as the pandemic began], and we were like, 'Hey, this is great; people are able to access drugs,'" said corresponding author Jeffrey Clement, a University of Minnesota PhD candidate in information and decision sciences, reflecting on a conversation he had with his sister and fellow author Maura Jacobi, MD, a St. Paul family practitioner.

"But in some cases, some physicians may not actually want patients to have a greater supply of medication."

Because of this, the study looked at changes in DOS, likelihood of discontinuation, as well as macro-level claim quantities from May 2019 to August 2020 to identify prescription changes. The researchers analyzed Symphony Health data, which covers 93% of all US prescriptions in this period, or 9.4 billion US drug claims from 252 million patients. 

Little discontinuation in addiction, immunosuppressive drugs

Similar to findings from a previous IQVIA webinar about the early pandemic months, the researchers found that March 2020 had a peak of prescription drug claims (543.7 million) followed by a steep decline. By August, demand had still not met 2019's baseline, with 12.05% fewer claims, which may be due to a stockpiling surpluses or, on the opposite end of the spectrum, access difficulties.

Out of the six drugs, the likelihood of discontinuation actually decreased for buprenorphine/naloxone (addiction management -0.59%) and tacrolimus (immunosuppression, -0.15%), which the researchers say could reflect the higher level of oversight involved with drug administration.

Dexmethylphenidate hydrogen chloride (for ADHD), haloperidol (for antipsychosis), norgestrel/ethinyl estradiol (hormonal contraceptive), and selective serotonin reuptake inhibitor escitalopram oxalate had 2.84%, 1.49%, 0.62%, and 0.57% increased rates of discontinuation, respectively.

"As the estimates generated by a linear probability model are absolute (instead of relative) percentages, the estimates imply that hundreds of thousands of patients were affected just across the six therapies we evaluated," the researchers write, adding that these drugs can affect issues such as family planning and mental health.

Assessing new, returning patients

Overall, the amount of new patients per month significantly decreased during pandemic months for all six of the assessed drugs except haloperidol, with the greatest deficits seen in dexmethylphenidate hydrogen chloride (down 45.8%) and norgestrel/ethinyl estradiol (down 21.4%) from March to August 2020.

The analysis could not determine why this occurred, but a variety of factors may have had an impact, including care-seeking behavior or a change in lifestyle or coverage (eg, the loss of a job that would have required or covered the drugs). Clement notes that none of the drugs had significant manufacturing disruptions, COVID-related or otherwise.

DOS changes for returning patients ranged from being nonsignificant (haloperidol) to a decrease of 2.81 days (norgestrel/ethinyl estradiol) to an increase for tacrolimus (5.58 days). As DOS and discontinuation likelihood do not have a linear relationship, Clement explains that these two measurements help show different facets of a complex dataset with variation not only across but also within drug classes.

Even without understanding why certain trends occurred, the awareness around prescription discontinuation can spark tangible changes on the local level, says Clement. Pharmacies can pull reports to find patients who never received their refill prescriptions, or insurance companies can find out whether patients who could file refill claims did. Hospitals can run similar reports.

"It's an opportunity for their care team, in a nonjudgmental manner, to be able to keep patients on medication, to ask if they're experiencing any challenges," he says.

"It's not unusual for a doctor to talk to patients and for them to say, 'Oh yeah, I have no trouble with insurance companies or stocking up.' But then there's that one patient at the end who was impacted. … That's who clinicians should look for."

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