Assessing Medication Pick-Up Rates at a Student-Run Free Health Clinic

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Introduction
2][3] High levels of medication adherence (>80%) are associated with lower disease-related medical costs and a reduced risk of hospitalization in patients with chronic conditions such as diabetes and hypercholesterolemia. 2 One study performed at a free clinic found that 55% of all medication-related problems identified within the patient population were of medication nonadherence. 4[7] The first barrier to medication adherence is the need for prescription pick up.In typical outpatient practice, a provider writes a prescription that the patient must fill at an external pharmacy.9] Underserved patients may not have the transportation or financial resources required to successfully obtain medications from an external pharmacy.Student-run free clinics can alleviate these burdens and increase the rate of medication pick up by establishing an on-site pharmacy.
The aim of this study is to compare the prescription pick-up rate in patients served by a studentrun free clinic for prescriptions filled at an external pharmacy and those dispensed at the point of service from an on-site pharmacy.To our knowledge, this is the first published study assessing rates of prescription pick up among patients seen at a student-run free clinic.

Setting
The Student Health Action Coalition (SHAC) Clinic was established in 1967 by the University of North Carolina at Chapel Hill as a free healthcare clinic to serve the needs of the surrounding community.The clinic is open every Wednesday evening year-round, and is open to both appointments and patient walk-ins.The clinic is divided into two sections: Acute Care and Bridge to Care.Acute Care sees patients with immediate needs, such as infections or routine physical exams.Bridge to Care provides management for patients with diabetes or hypertension and connects them to a primary care physician within six months.
The in-house pharmacy at SHAC Clinic is structured to minimize barriers that patients may face in obtaining their medications.SHAC Pharmacy is registered as a limited-service pharmacy with the North Carolina Board of Pharmacy and may dispense medications under the direct supervision of a licensed pharmacist ("SHAC Dispensed").Patients can immediately obtain medications, at no cost, from a formulary of 44 commonly used medications.For non-formulary or out-of-stock medications, patients receive a paper prescription that can be filled at no cost at our community pharmacy partner, Carrboro Family Pharmacy ("SHAC Pays") that is located 2.3 miles from the clinic.These paper prescriptions may also be filled at other pharmacies, but at the patient's expense.

Study Sample
This study was a retrospective patient chart review that was exempted from review by the Institutional Review Board at the University of North Carolina -Chapel Hill.All prescriptions documented as SHAC Pays or SHAC Dispensed on the clinic pharmacy log and written between June 17, 2014 and March 30, 2015 were included for analysis.The clinic pharmacy log is a document updated separately from the electronic medical record (EMR) by clinic pharmacy managers to consolidate tracking of prescriptions written and medications dispensed.All prescriptions identified on the clinic pharmacy log were verified in the EMR to ensure accuracy of the information.Prescriptions written for patients under the age of 18 were excluded from analysis.

Measures
The information collected for each prescription consisted of patient name, medical record number, Acute Care or Bridge to Care status, medication name, date prescription was written, number of refills provided, and, if applicable, date of each medication pick up as documented on invoices from Carrboro Family Pharmacy (CFP).Prescription pick up was validated by reviewing invoices from CFP on the SHAC Pays account and matching each purchase at CFP with its corresponding prescription on the clinic pharmacy log.Any prescription or refill entered on the log that could not be matched to a corresponding purchase at CFP was recorded as "Not Picked Up." The primary outcome of this study was the rate of prescription pick up, defined as the percentage of written SHAC Pays or SHAC Dispensed prescriptions and refills that were picked up by the patient.Secondary outcomes were median time from date of prescription issuance to date of medication pick up, and adherence rates for the Acute Care and Bridge to Care subgroups.Per SHAC Pharmacy policy, each prescription may only be written for a 30-day supply.Therefore, for the purposes of this study, the date of issuance for refilled prescriptions was considered to be 30 days after each preceding pick up date.For SHAC Dispensed prescriptions, the date of pick up was the same as the date of issuance.

Statistical Analyses
Fisher's exact test was used to compare the primary outcome, and an odds ratio was calculated to compare the secondary outcome of prescription pick-up rate between subgroups.Mann-Whitney U test was utilized for a comparison of median time to prescription pick up between the two groups.At a 95% confidence interval, a 2-tailed pvalue less than 0.05 was considered statistically significant.Analyses were performed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington).

Results
A total of 64 unique patients received SHAC Pays prescriptions during the studied time period.Two patients were under the age of 18 and were excluded from analysis.For the 62 included patients, 158 SHAC Pays prescriptions were provided.A total of 61 unique patients received SHAC Dispensed prescriptions during the studied time pe- For the primary outcome, prescriptions dispensed from clinic had a significantly higher pickup rate than SHAC Pays prescriptions (100% vs. 58.2%;p< 0.0001).There were 111 SHAC Dispensed prescriptions picked up from the SHAC clinic pharmacy (100%) and 92 SHAC Pays prescriptions picked up from the community pharmacy partner (58.2%).
Among patients who picked up their SHAC Pays prescriptions and/or refills, the median time to prescription pick up was 3 days, with a range of 0 to 86 days (Figure 1).Zero days indicates a refill that was picked up on time or earlier than 30 days following the previous fill.For SHAC Dispensed prescriptions, pick up date was always on the date of issuance, or 0 days.The difference between median times to pick up was statistically significant between the SHAC Pays and SHAC Dispensed populations (p < 0.0001).Seventy-three percent of prescriptions were picked up within 10 days of issuance or expected refill.
Within the SHAC Pays group, Bridge to Care patients picked up 59 out of 98 prescriptions (60.2%), while Acute Care patients picked up 33 out of 60 prescriptions (55.0%) (Figure 2).There was not a significant difference between the two groups (odds ratio for Bridge to Care pick up, 1.24; 95% CI, 0.65 to 2.37; p=0.52).The median pick up time was 2 days for Acute Care patients and 4 days for

Discussion
The primary objective was to compare the rates at which patients picked up SHAC Dispensed and SHAC Pays prescriptions.The results of this study indicate that point-of-care dispensing through the SHAC Dispensed system significantly improved patients' rates of obtaining their medications successfully, compared to the SHAC Pays system.Our results align with a similar study, conducted in an hospital emergency department, that found significant improvements in prescription pick up when dispensing on-site instead of sending patients to an external pharmacy. 8The median time to prescription pick up for SHAC Pays prescriptions was just 3 days after the written date or expected refill date, suggesting that the majority of patients who did pick up from the external pharmacy were generally timely in doing so.However, when compared to patients who instantly acquired their medications while being seen at SHAC Clinic, the SHAC Pays system clearly caused a significant delay in patients receiving their medication.This delay is also partly a consequence of having only a single community pharmacy partner, which creates a barrier to adherence for patients with limited transportation or for those who cannot visit the pharmacy during business hours.
Though patients in the Bridge to Care population were 24% more likely than Acute Care patients to pick up their prescriptions, this difference was not statistically significant.The trend toward improved pick-up rate may be explained by the structure of Bridge to Care, in which patients are seen by the same student medical team for all return visits.In contrast, Acute Care patients will see a different medical team with each visit to SHAC.The development of a long-term and positive provider-patient relationship has been shown to increase medication adherence. 10he results of this study engender significant opportunities for improved practices at SHAC Clinic and other free healthcare clinics like it.The clinic is actively engaging with local community pharmacies to establish a network in which patients can readily obtain SHAC Pays medications.In addition, strategic expansion of the clinic's medication formulary will be considered, as an increase in the proportion of SHAC Dispensed prescriptions could improve overall medication adherence within our patient population.

Limitations
The authors of this study acknowledge several limitations.First, the data collected in this study could only be used to determine whether patients were in possession of their prescribed medications.However, successful prescription pick up does not guarantee medication adherence.Second, some SHAC Pays prescriptions could have been filled at a pharmacy other than CFP, at the patient's expense.These prescriptions could not be captured for the purposes of the primary outcome of this study and were therefore considered as "Not Picked Up." Third, data collection for this study was dependent on thorough documentation of all prescriptions in both the clinic pharmacy log and the SHAC Clinic EMR system.In analyzing our data, we encountered documentation errors that compromised our ability to fully capture all data points.For example, some medical teams failed to enter prescribed medications into patient EMR charts.Per this study's methodology, prescriptions that were not adequately recorded could not be included in the primary outcome assessment.These omitted prescriptions have an unknown effect on this study's reported outcomes.

Conclusion
In conclusion, pick-up rates for SHAC Pays prescriptions was negatively impacted by the additional hurdle of a visit to an external pharmacy for medication pick up.. Prescription pick up is the first step to medication adherence, a crucial component of optimizing patient outcomes.Therefore, student-run free clinics have an ethical and societal obligation to help improve their patients' medication pick-up rates and subsequent adherence Also, clinics like SHAC are supported by private financial donations and endowments.To be good financial stewards, clinic leadership must ensure that resources and volunteer efforts are being utilized most effectively for the care of each patient, which should then translate to sustainable benefits beyond the clinic walls.This study should motivate the leadership of other studentrun clinics to evaluate the outcomes of their medication distribution services.Through these analyses, increased discussion within and among student-run clinics regarding best practices can unlock new methods to improve patient care.

Figure 2 .
Figure 2. Medication pick-up rates by patient population

to Care Adherence Rate Journal of Student-Run Clinics
| Assessing Medication Pick-Up Rates at a Student-Run Free Health Clinic journalsrc.org| J Stud Run Clin 3;1 | 4