A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes

Bharathi Ramachandran, Connie M. Trinacty, J. Frank Wharam, O. Kenrik Duru, Wendy T. Dyer, Romain S. Neugebauer, Andrew J. Karter, Susan D. Brown, Cassondra J. Marshall, Deanne Wiley, Dennis Ross-Degnan, Julie A. Schmittdiel

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background: Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. Objective: To assess an intervention to encourage MOP services to increase its use and medication adherence. Design: Randomized encouragement trial. Patients: 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. Intervention: Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. Measurements: We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. Results: During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. Conclusion: This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients. Trial Registration: ClinicalTrials.gov registration number: NCT02621476

Original languageEnglish (US)
JournalJournal of general internal medicine
StateAccepted/In press - 2020
Externally publishedYes


  • diabetes
  • encouragement trial
  • mail order pharmacy
  • medication adherence

ASJC Scopus subject areas

  • Internal Medicine


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