The effectiveness of care coordination on medication adherence among high-need, high-cost commercially insured beneficiaries: A randomized controlled trial.

BACKGROUND

High-need, high-cost (HNHC) beneficiaries experience life stressors that complicate their medication self-management. Care coordination programs may improve medication-taking behavior, including for chronic conditions that require daily medication adherence.

OBJECTIVE

To determine whether nurse-led care coordination is associated with improved adherence among an HNHC commercial population with a chronic condition.

METHODS

We analyzed data from a pragmatic, national randomized controlled trial of a comprehensive care coordination program conducted by a large national insurer and assessed its impacts on medication adherence in diabetes, atrial fibrillation, and hypothyroidism. We performed intention-to-treat (ITT) analyses (primary) and instrumental variable (IV) analyses (secondary) for HNHC beneficiaries from 2019 through 2022. Analyses compared treatment of control arms for metformin in diabetes (n = 3,602), statins in diabetes (n = 3,938), direct oral anticoagulants in atrial fibrillation (n = 326), and levothyroxine in hypothyroidism (n = 2,496). The primary adherence outcome was defined as proportion of days covered (PDC) greater than or equal to 80%, with continuous adherence measured as a secondary outcome. We used multivariate regression models to compare outcomes between arms. For the IV analyses, we used randomization status as the instrument. Covariates included age, sex, geographic location, plan type, and 18 comorbidity indicators. We also conducted sensitivity analyses limited to beneficiaries with baseline PDC less than 80%.

RESULTS

In the primary ITT analyses, we did not observe statistically significant differences between treatment and control arms in the percentage of beneficiaries with PDC greater than or equal to 80% for metformin (66% vs 68%, P = 0.22), statins (69% vs 70%, P = 0.55) or direct oral anticoagulants (71% vs 68%, P = 0.6). However, beneficiaries taking levothyroxine were more likely to have PDC greater than or equal to 80% than those assigned to control (77% vs 73%, P = 0.02). Similar results were observed in the secondary IV analyses. In the secondary ITT analyses examining adherence as a continuous outcome, we did not observe any differences between arms. Finally, in the sensitivity analyses limited to beneficiaries with baseline PDC less than 80%, we also found no adherence differences.

CONCLUSIONS

We found that care coordination did not improve medication adherence in HNHC beneficiaries. Our results align with prior studies and emphasize the challenges of improving adherence within a complex HNHC beneficiary population.

TRIAL REGISTRATION: ClinicalTrials.gov NCT04415515.