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Abstract

Objectives: To assess the impact of passive and active promotional strategies on patient acceptance of medica- tion therapy management (MTM) services, and to iden- tify reasons for patient acceptance or refusal.

Methods: Four promotional approaches were devel- oped to offer MTM services to eligible patients, includ- ing letters and bag stuffers (“passive” approaches), and face-to-face offers and telephone calls (“active” ap- proaches). Thirty pharmacies in a grocery store chain were randomized to one of the four approaches. Patient acceptance rates were compared among the four groups, and between active and passive approaches using hier- archical logistic regression techniques. Depending on their decision to accept or decline the service, patients were invited to take part in one of two brief telephone surveys.

Results: No significant differences were identified among the four promotional methods or between ac- tive and passive methods in the analyses. Patients’ most frequent reasons for accepting MTM services were po- tential cost savings, review of how the medications were working, the expert opinion of the pharmacist, and edu- cation about medications. Patients’ most frequent rea- sons for declining MTM services were that the partici- pant already felt comfortable with their medications and felt their pharmacist provides these services on a regular basis.

Conclusion: No significant difference was found among any of the four groups or between active or pas- sive approaches. Further research is warranted to identi- fy strategies for improving patient engagement in MTM services.

J Am Pharm Assoc. 2015;55:178–181. doi: 10.1331/JAPhA.2015.14091

Impact of passive and active promotional strategies on patient acceptance of medication therapy management services Alison L. Huet, Caitlin K. Frail, Leslie M. Lake, and Margie E. Snyder

The value of pharmacist-provided medication thera-py management (MTM) services has been demon- strated through improvements in clinical outcomes re- lated to medication use. Despite this, patient acceptance rates of MTM are lower than desired, varying from less than 1% to more than 50%, with an average of 14% to 18%. Variation results from differences in patient re- cruitment, opt-in programs versus opt-out programs, and differences in health care needs of those offered the service.4 With generally low acceptance rates, under- standing how to effectively recruit patients into MTM programs is important.

Barriers to patient participation include lack of un- derstanding of MTM, unclear provider roles relating to MTM, and patient perception of the need for such a ser- vice.5,6 Previous studies have identified the need to en- hance marketing efforts by taking into account patients’ perceptions and expectations. These studies have de- scribed the importance of clearly explaining the purpose of MTM, exhibiting a team-based approach to care, ex- plaining why the pharmacist is the optimal health care provider to provide MTM, focusing on those services

Alison L. Huet, PharmD, Pharmacist and Owner, Jackson Pharmacy & Wellness Center, Jackson Center, OH; at the time of project completion, PGY1 Community Pharmacy Resident, Kroger Pharmacy Central Division, Indianapolis, IN

Caitlin K. Frail, PharmD, MS, BCACP, Assistant Professor, College of Pharmacy, University of Minnesota, Minneapolis, MN; at the time of project completion, Community Practice Research Fellow, College of Pharmacy, Purdue University, Indianapolis, IN

Leslie M. Lake, PharmD, Clinical Care Coordinator, Kroger Pharmacy Central Division, Indianapolis, IN

Margie E. Snyder, PharmD, MPH, Assistant Professor of Pharmacy Practice, College of Pharmacy, Purdue University, Indianapolis, IN

Correspondence: Alison L. Huet, PharmD, 101B E. Pike St., Jackson Center, OH 45334; [email protected]

Acknowledgments: Purdue University Statistical Consult- ing Service for statistical support.

Disclosure: The authors declare no relevant conflicts of in- terest or financial relationships.

Funding: American Pharmacists Association Foundation Incentive Grant and Lilly Endowment grant: Plan for Preemi- nence for Purdue University. A portion of Dr. Snyder’s effort was supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not neces- sarily represent the official views of the Agency for Health- care Research and Quality.

Previous Presentations: American Pharmacists Associa- tion Annual Meeting, Los Angeles, CA, March 1–4, 2013; Great Lakes Pharmacy Residency Conference, West Lafay- ette, IN, April 24–26, 2013.

Received February 11, 2014. Accepted for publication July 7, 2014. Published online in advance of print February 6, 2015.

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patients perceive as most beneficial (such as the per- sonal medication list), using patient-friendly language (i.e., “medication check-up” and “medication manage- ment”), and increasing overall exposure to MTM.5–7

Although these studies have identified patient pref- erences for marketing techniques, no studies to date have been conducted to implement these strategies in a prospective, randomized way.

Objectives The primary objective of this pilot project was to mea- sure patient acceptance rates of pharmacist-provided MTM services by comparing four distinct promotional strategies: face-to-face offers, telephone calls, letters, and bag stuffers. The secondary objective was to evaluate reasons patients accepted or declined to participate in the service.

Methods This study was approved by the Purdue University In- stitutional Review Board. A convenience sample of 30 locations of a grocery-store-based community pharma- cy chain in Indiana was chosen to participate based on expressed interest in providing MTM services. Pharma- cies were randomly assigned to one of the four promo- tional methods. These were categorized as either passive (letters and bag stuffers) or active (face-to-face offers and telephone calls) strategies.

Although four different strategies were used, the promotional messages and materials used uniform language preferred by patients in previous research.6 Before data collection, pharmacists at participating loca- tions were trained on MTM delivery and use of the pro- motional approach assigned to their site. Pharmacists providing verbal promotional messages (telephone calls or face-to-face) received a brief script to follow with the patient and a list of follow-up points and questions for use if the patient was not immediately interested. Let- ters were mailed directly to patients from the pharmacy chain’s corporate office. Bag stuffers were attached to eligible patients’ prescription bags by pharmacy staff.

Because of staffing changes, one of the assigned sites did not participate. Data were collected from 29 locations over a 3-month period (January to April 2013). Adult, nonpregnant patients who had not received MTM ser- vices at any time in the past year were eligible for the study if identified by an MTM vendor and assigned to the study pharmacies for MTM as of January 2013. A to- tal of 397 patients were assigned to the study pharma- cies for MTM as of the beginning of the study period; 22 were excluded from the study as they had received an MTM appointment in the past year, and 25 patients were ineligible as they were younger than 18 years. The remaining 350 patients were included in this study.

The primary outcome measure was rate of patient acceptance of MTM, defined as those patients who came

in and met with the pharmacist for their MTM appoint- ment, with documentation completed and submitted during the 3-month study period. The time frame for this pilot study was chosen because the primary inves- tigator (AH) was completing a 12-month residency pro- gram and this was a residency project.

All eligible patients were invited to take part in a brief telephone survey in conjunction with the offer to participate in MTM. Participants were asked to contact the primary investigator to receive more details about the survey, provide verbal consent, and complete one of the surveys. The survey was administered before the ap- pointment if the patient accepted the offer. This allowed the survey to specifically elicit information about the promotional strategies rather than the service itself.

The surveys gathered information about why the patient accepted or declined the appointment (see the online Appendix for survey items, available on JAPhA. org in the Supplemental Content section). Demographic data collected included age, gender, race, ethnicity, edu- cation level, number of medications, and chronic disease states. The survey required 10 to 15 minutes for comple- tion by phone. All survey participants were offered a $20 gift card as an incentive.

Patient acceptance rate reports were exported to Mi- crosoft Excel 2010. Patient acceptance rates were com- pared among the four groups, and between the active and passive categories, using hierarchical logistic regres- sion techniques to control for nesting of patients within pharmacy locations. These analyses were performed using SAS v. 9.3. Descriptive statistics were computed for information gathered from participant surveys using Microsoft Excel 2010.

Results A total of 15 patients (4%) accepted the offer and com- pleted their MTM appointment over the course of the 3-month study period. The mean age of patients accept- ing was 70 years, ranging from 49 to 85. Of those who accepted, the majority were in the telephone group (n = 10), followed by the letter group (n = 3) and the face-to- face group (n = 2). No patients assigned to bag stuffer stores accepted the offer.

Results of the hierarchal logistic regression showed no significant differences in pairwise comparisons of the four strategies. Telephone calls resulted in more MTM appointments than either bag stuffers (10 vs. 0) or face- face offers (10 vs. 2); however, neither comparison was statistically significant (P = 0.0526 and P = 0.0805, respec- tively). There was no significant difference between the active and passive promotional approaches when the approaches were dichotomized (P = 0.26). Age and gen- der were also included in the model but were not found to be significant predictors of patient acceptance.

A total of 14 patients participated in the survey; 10 respondents had accepted the service, while 4 partici-

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pants had declined. The most frequently cited reasons for accepting were potential cost savings (n = 7), a re- view of how the medications are working (n = 7), the expert opinion of the pharmacist (n = 6), and education about prescriptions, over-the-counter medications, vita- mins, and herbals (n = 6). The most frequently cited rea- sons for declining the service were that the participant already felt comfortable with their medications (n = 4) and the perception that their pharmacist provides these services on a regular basis (n = 4).

Participants were also asked about their familiar- ity with MTM; 43% (n = 6) of participants indicated that they had previously heard of MTM services. Five (36%) participants stated that they had a caregiver who as- sisted them with their medications. Of those five, four stated that it would be helpful to involve their caregiver in the MTM appointment.

Six of the participants who accepted MTM services would have been willing to pay out-of-pocket for ser- vices before they had met with the pharmacist. Of those who stated a range they would be willing to pay for ser- vices, the mean amount suggested was $32 ($10–$100).

Discussion Although no significant differences were found in our analyses, the telephone outreach group garnered the most positive responses in our small pilot project. Tele- phone calls were active and pharmacist driven, allow- ing the pharmacist to proactively contact the patient without relying on the patient to visit the pharmacy. Because of the limited time frame of the study and the increased use of 90-day supplies of long-term medica- tions, pharmacists likely had fewer opportunities to encounter patients face-to-face. Furthermore, prior re- search has described limited success with passive ap- proaches.8 Interestingly, telephone calls resulted in more MTM appointments than the other “active” approach (i.e., face-to-face). While not significantly significant, this

may have contributed to the nonsignificant difference between the dichotomized active and passive strategies.

Prior research has described patient preference for receiving information on community pharmacy services through bag stuffers, which was an unsuccessful ap- proach in our study.9 However, our patient population had already been specifically identified by their Medi- care Part D plan as likely to benefit from this service, so such a general approach may not have been successful.10 This group may benefit from speaking directly to a phar- macist who could explain particular service benefits and answer patient questions.

Reasons for patients declining MTM services were not unlike those previously described in research on community pharmacy services marketing.11 Communi- ty pharmacists have described patients’ perceived reluc- tance to participate in services related to long-term med- ications they have been using for an extended period.12 Patients may feel falsely confident because of their fa- miliarity with their medications. This points to the need for better patient education on the additional benefits of MTM beyond traditional prescription counseling.

Interestingly, more than one-third of the survey par- ticipants reported they believed having a caregiver pres- ent would be helpful. Future research should address MTM promotion techniques directed toward caregivers.

Limitations There were several limitations to our study.

The acceptance rate was low, which was anticipated, as this is a common challenge to providing MTM ser- vices. Most of the pharmacists at the locations were new MTM providers, which may have contributed to slow uptake of the service. There was also a change in MTM eligibility directly before the study began, decreasing potentially eligible patients from more than 800 to 397. Patients had to proactively contact the investigator to complete the survey, likely reducing the response rate for this part of the study.

Table 1. Pairwise comparisons among MTM promotional strategies in community pharmacies

Pairwise comparisons

Promotional strategies Accepted offers

N (%) Telephone Face-to-face Bag stuffers Letters

Active promotionsa

Telephone (n = 85) 10 (12) … 0.080 0.053 0.170 Face-to-face (n = 85) 2 (2) … 0.634 0.594 Total (n = 170) 12 (7)

Passive promotionsa

Bag stuffers (n = 95) 0 (0) … 0.341 Letters (n = 85) 3 (4) … Total (n = 180) 3 (2)

Abbreviation used: MTM, medication therapy management. aDichotomized comparison of active versus passive interventions resulted in a nonsignificant difference (P = 0.26).

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Additionally, the 3-month time frame for the study limited our primary analysis. Those patients who re- ceived a promotional intervention in the pharmacy (face-to-face offer or bag stuffer) may have had limited opportunity to receive the information, particularly if they typically receive 90-day medication supplies. Con- tact through letters and telephone calls could happen more frequently without relying on the patient coming into the pharmacy.

There was some crossover of promotional efforts in a limited number of patients. One of the pharmacists in the letter group additionally made telephone calls to patients, since this was a typical MTM recruitment ap- proach in their usual practice (two of six accepted ap- pointments). Because of this error in study execution, it is unclear in those cases which technique prompted the patient to accept the offer.

Conclusion Our analysis found no significant differences between four promotional strategies aimed at increasing patient participation in MTM programs. The telephone group was more frequently successful in our small pilot study. This points to a need for more active outreach to patients to help them understand the value of MTM rather than using passive methods. Further research on MTM pro- motional strategies is needed.

Patients who accepted MTM were interested in cost savings, pharmacists’ expert opinion, additional edu- cation regarding all medications, and reviewing how well medications were working for them. These ben- efits could be emphasized to patients eligible for MTM. Of those who declined, all of the patients stated their pharmacist already provides these services on a regular basis. This points to the importance of distinguishing be- tween MTM and patient counseling.

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