key: cord-0765972-rsoo4mtk
authors: Vordenberg, Sarah E.; Zikmund-Fisher, Brian J.
title: Older Adults’ Strategies for Obtaining Medication Refills in Hypothetical Scenarios in the Face of COVID-19 Risk
date: 2020-06-25
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2020.06.016
sha: 2975ef7706df0b2a87491848893d2e48b72e6c84
doc_id: 765972
cord_uid: rsoo4mtk

Abstract Objective To identify whether older adults would avoid going to the pharmacy (e.g., by restricting medications or requesting delivery) due to the risk of COVID-19. Our secondary objectives were to determine which types of medications older adults may be more likely to restrict and to determine factors that influence these decisions. Design Cross-sectional survey experiment in which participants read 6 scenarios, each stating they had a three-day supply of a particular medication remaining. Setting and participants National web-based survey distributed to 1,457 U.S. adults 65 years and older by Dynata during March 25 – April 1, 2020. Outcome measures Participants reported whether they would go to a pharmacy, have a medication delivered, or restrict use of each medication. They reported their perceptions and experiences with COVID-19, health risk factors, preferences for more or less care (Medical Maximizer-Minimizer), medication attitudes (Beliefs about Medicines Questionnaire), health literacy, prescription insurance status, and demographics. Results Most participants (84%) were told to shelter in place, but only 12% reported attempting to obtain extra medications. Participants most often reported that they would go to the pharmacy to obtain each medication (range tramadol 48.9% to insulin 64.9%), except for zolpidem which they were most likely to restrict (45.4%). Participants who reported risk factors for COVID-19 (beyond age) were just as likely to go to the pharmacy as those without. In multinomial logistic regression analyses, women and the oldest participants were more likely to seek delivery of medications. Restricting medications was most common for 2 symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizing-minimizing preferences) were associated with such decisions. Conclusion Many older adults intend to continue to go to the pharmacy to obtain their medications during a pandemic, even those who have health conditions that further increase their risk from COVID-19.

Background • Adults 65 years and older are at higher risk for severe illness and injury from COVID-19, and their risk is increased if they have chronic health conditions such as cardiovascular disease or diabetes.

• The Centers for Disease Control and Prevention recommends that older adults have several weeks of medication at home as part of emergency preparedness.

• Older adults who do not have extra medications face a difficult tradeoff: Go to the pharmacy and risk exposure to COVID-19, ration or forgo their medications and risk worsening health, or have medications delivered and increase that person's risk of illness.

• Over one-half of older adults reported that they would continue to go to the pharmacy.

Participants who reported risk factors for COVID-19 were just as likely to intend to go to the pharmacy as those who reported no risk factors.

• Women and the oldest participants (within our older adult sample) were more likely to seek delivery of medications.

• Restricting medications was most common for 2 symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizingminimizing preferences) were associated with such decisions.

In 2020, COVID-19 is a national emergency and pandemic. 1 ,2 Within a few months' time, the United States went from identifying its first infection from the novel coronavirus SARS-CoV-2 to having over 100,000 deaths. The disease has proved particularly challenging to control because it spreads relatively easily through expelled droplets and because significant numbers of infected patients are asymptomatic.

The vast majority of COVID-19 related deaths in the U.S. have been among adults 65 years and older, especially those with health conditions like cardiovascular disease, diabetes, and lung disease. 3 The

Centers for Disease Control and Prevention (CDC) recommended that the best way to prevent the illness is to avoid being exposed to the virus, such as by staying home as much as possible, 4 which led to stayat-home public health orders across most of the United States.

Given how quickly this situation evolved and the presence of prescription insurance limits on prospective medication refills, many older adults may not have extra medications at home. If so, they face a difficult tradeoff in an era of prevalent COVID-19 disease: Older adults who go to the pharmacy risk exposure to COVID-19, particularly as sick patients may be obtaining medications from the pharmacy. In contrast, older adults who forgo their medications are at increased risk of worsening health conditions. [5] [6] [7] [8] [9] [10] [11] This could result in patients being hospitalized for a health condition not directly related to COVID-19. Such preventable hospitalizations represent a significant systemic problem given that the patient may become infected with COVID-19 and that their hospitalization also diverts resources from other patients with critical needs at a moment when the health system is likely to be critically overburdened. Alternatively, patients may have their medications delivered, either through a program at the pharmacy or by a family member or friend. However, person-to-person contact when the medication is delivered still represents increased risk for the older adult, and some may have ethical concerns about putting others at risk on their behalf.

We sought to identify how older adults, who may have chronic medical conditions, make decisions about their maintenance medications during a pandemic. The primary objective of this study was to identify the proportion of older adults who intended to address an imminent need for a medication refill by going to the pharmacy, requesting delivery, or by restricting medication use. Our secondary objectives were to determine which types of medications (e.g., based on their indication for use) older adults may be more likely to forgo or ration and to determine what factors influence how each person makes these types of decisions.

We recruited a sample of US adults 65 years and older using Dynata (Plano, Texas), which maintains a demographically diverse Internet panel of people who opt-in to taking selected surveys. 12 

In the survey, we first provided background information about Covid-19 to ensure a common framing of the problem and potential risk. (Appendix A) Participants were then asked to imagine that they had been instructed to shelter in place due to Covid-19 and were provided a description of this term. We specified that pharmacies were currently open and that people were allowed to leave their home to obtain essential services, such as going to the pharmacy.

We then asked participants to imagine that they take a specific medication and were give a brief description of why the medication is used. (Table 1 ) We selected medications that are commonly used in clinical practice by older adults for a variety of health conditions. We aimed to choose medications that we anticipated older adults would perceive as posing various amount of risk for significantly worsening health if they went without the medication (e.g., albuterol for shortness of breath compared with zolpidem for difficulty sleeping). We asked participants to imagine having only three days of medication remaining but a sufficient amount of all of their other medications. Immediately after each medication, participants reported what they would do in that situation: go to the pharmacy to obtain the medication, decrease the amount of medication that they are using to make it last longer, ask someone else to deliver the medication, or stop the medication. Participants could only choose one outcome for each medication.

This was repeated so that each participant responded to a total of six medications. We presented both the medications and the response options in random order, and participants were instructed to treat each scenario (i.e. medication) separately.

Subsequently, participants reported their perceived level of seriousness of Covid-19 using a sliding scale

(not serious at all to extremely serious) that was converted to a 100-point scale during data analysis. We also inquired whether there had been reports of Covid-19 in their local community, if participants had been told to shelter in place, whether participants believed they had personally been infected with Covid-19, and whether participants personally knew anyone who they believe to have Covid-19. Given limited testing, we specified that the last two items were their beliefs, regarding of whether testing had occurred.

We also asked if participants had attempted to obtain extra prescription medications and their experience with each type of medication used in the hypothetical scenarios. (Table 1) Participants then answered one question about their self-reported health (1 = poor, 5 = excellent) which has been inversely associated with mortality. 14 We asked participants if they currently have any of the following health conditions that could increase their risk of serious complications from Covid-19: cancer, diabetes, heart disease, human immunodeficiency virus, hypertension, lung disease. We also asked if they are immunocompromised, have ever had a cardiovascular event, and about current and previous tobacco use. For our statistical analysis, we collapsed this to either having no or one or more risk factors.

We obtained self-reported health literacy using a one item statement related to confidence filling out medical forms (1 = not at all, 5 = extremely), which was collapsed for analysis purposes into 2 groups (1-3 vs. 4-5). 15, 16 Participants completed two validated scales plausibly related to their attitudes about medications. First, participants completed the Medical Maximizer-Minimizer single-question measure (MM1) which measures people's overall preferences for receiving more versus less healthcare. [17] [18] [19] [20] [21] The second scale that participants completed was the Beliefs about Medicines Questionnaire (BMQ) which subscales focused on necessity of medications (BMQ Specific-necessity), concerns about medications (BMQ Specificconcern), and medication harms (BMQ-General). [22] [23] [24] [25] Higher scores on BMQ Specific-necessity indicated more positive beliefs about medications, whereas higher scores on the other two subscales indicated more negative beliefs about medications. Finally, we collected demographic characteristics and whether or not they had prescription drug insurance.

Immediately after reading about each medication, participants reported whether they would go to the pharmacy, decrease the amount of medication they were taking, ask someone else to deliver the medication, or stop the medication. This response served as the primary outcome of the study.

We describe the reported action that participants would take for each medication. Given the small number of people who selected decreasing or stopping each medication, we combined these two outcomes to create a restrict medications variable. We used multinomial logistic regression to examine characteristics associated with choosing delivery or restricting medications (vs. going to the pharmacy) for each medication scenario. Regressions included whether or not the person reported health risk factors, selfreported health, prescription drug insurance, MM1, BMQ, health literacy, and demographics. Based on the findings of other studies focused on medication decision-making among older adults, we analyzed separately the BMQ-general subscale as well as both BMQ Specific sub-scales: BMQ Specific-Necessity and BMQ Specific-Concern. 26, 27 Participants who completed the survey in less than 3 minutes, did not complete the survey, or reported an age < 65 years were excluded. We used a statistical significance level of P<0.05. All analyses were conducted with Stata, version Stata SE 15.0 (StataCorp).

A total of 1,652 individuals started the survey. We excluded participants who did not complete the survey (n=40), were less than 65 years of age (n=154), or who completed the survey in less than 3 minutes (n=1), leaving a final analytical sample of 1,457 respondents. reporting a score between 75 to 100. The majority of respondents reported cases in their local community (n=1,026, 70.5%) and had been told to shelter in place (n=1,218, 83.8%). Few participants believed they personally had COVID-19 (n=37, 2.5%) or knew someone who was infected (n=159, 10.9%).

Only 12.3% of participants (n=155) who reported taking prescription medications attempted to obtain extra medications. As shown in Figure 1 , participants most often reported that they would go to the pharmacy to obtain each medication (range tramadol 48.9% to insulin glargine 64.9%), except for zolpidem which they were most likely to restrict (45.4%).

Participants who reported one or more risk factors associated with poor outcomes when infected with COVID-19 were just as likely to intend to go to the pharmacy as those who reported no risk factors for each of the 6 medications considered (49.9% for no risk factors and 51.1% for 3 or more risk factors).

This pattern was replicated in a follow-up analysis that treated risk factors as a continuous variable (data not shown).

On average, approximately one-quarter of participants (27.5%) reported that they would have a medication delivered, ranging from 18.9% for zolpidem to 34.5% for albuterol ( Figure 1 ). Female gender was the only characteristic that predicted intent to have medication delivered across all six medications (Table 3 ; see Appendix B for full regression details). Participants who were older also tended to have medications delivered. This pattern was statistically significant for atorvastatin, insulin glargine, tramadol, and zolpidem and trended in the same direction for albuterol (p=0.06) and escitalopram (p=0.09). No other factors were significant predictors of intent to have medications delivered.

There was wide variation in the percent of patients who reported that they would restrict their medication.

The medications that participants were least likely to decrease or stop were insulin glargine (3.4%) and albuterol (4.7%), while participants were most likely to report restricting tramadol (26.5%) or zolpidem (45.4%), two medications used to treat the non-life-threatening symptoms of moderate pain and insomnia.

The predictors related to restricting medications were similar for these two medications (Table 3 ; see

Appendix B for full regression details). Participants who were older or female gender were more likely to restrict both medications, but these characteristics were not predictors of restricting any other medications. Participants with a stronger preference towards taking action related to their health based on MM1 or who reported better self-reported health were less likely to restrict these medications. MM1 was not correlated with any other medications while self-reported health was also positively correlated with decreased intention to restrict atorvastatin and escitalopram.

Beliefs about medications also significantly predicted intent to restrict several medications. Participants who had more positive beliefs about the necessity of medications based on BMQ Specific-necessity reported decreased intent to restrict escitalopram or tramadol. Participants with more concerns about medication harms based on BMQ General were more likely to restrict all of the medications except tramadol and zolpidem.

Over one-half of older adults surveyed reported that they would continue to go to the pharmacy to obtain prescription medications during the COVID-19 pandemic. Participants who reported risk factors for the infection (beyond age) were just as likely to go to the pharmacy as those without. Restricting medications was most common for two symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizing-minimizing preferences) were associated with such decisions.

Many pharmacies are exploring strategies to encourage patients to continue to obtain their medications, but to do so without going into the store, such as having medications dropped off at the patient's home, sent via mail, or even delivered by drone. 30, 31 Other strategies older adults may consider using to decrease the frequency of going to the pharmacy include obtaining early refills of medications in light of the pandemic, obtaining a 90 day supply of medication, and enrolling in medication synchronization programs. However, our works suggests that older adults may be reluctant to utilize some of these services. While we did not explore why participants preferred to go to the pharmacy, one barrier that older adults may face is that some programs require or encourage the use of technology to sign up or manage participation. Nearly one-half of adults 65 years and older do not have a smartphone and one-third have never used the internet. 32.33 While it can be challenging to fit in with the pharmacy workflow, pharmacy staff may consider providing support so that older adults can enroll in these programs. Given participants in this study used the internet to complete this survey, technology may not be a significant barrier to utilizing these program. A more challenging issue to address is that physical distancing may lead to social isolation and loneliness among older adults. [34] [35] [36] [37] It is possible that older adults are seeking to continue their usual activities that have been deemed essential, such as going to the pharmacy, in order to increase their social interactions. While pharmacists may not be in a position to directly address social isolation and loneliness, they should consider becoming familiar with national and local resources that are available to their patients.

While we are concerned about the rate at which older adults report that they would go to the pharmacy to obtain their medications, there are two positive findings in our study. First, older adults intend to continue to take their medications as prescribed. Medication adherence is important to prevent hospitalizations, particularly given the limited hospital resources available in many communities. 42,43 Second, older adults were generally able to differentiate medications that are critical to continue (e.g., insulin) from those that can be used as needed to manage symptoms (e.g., zolpidem). Importantly, we provided the indication for The primary limitation of our study was that participants were asked to imagine hypothetical scenarios, in most cases about medications that they were not currently taking. The approach that respondent's selected to manage running out of each medication may not align with their real-world actions. We also acknowledge that we limited our exploration to six medications and this does not capture the diversity of medications or health conditions for which older adults receive treatment. Furthermore, we did not specify if going to the pharmacy involved physically going into the store as some stores offer alternatives such as drive-through or curbside pickup which would decrease risk of exposure. Additionally, we chose to combine delivery by friends or family with delivery by professional services which prevents us from making conclusions about whether participants would be open to one approach over another. Although our sample included substantial demographic diversity and was drawn from a panel that includes members from across the U.S., we make no claims that it is representative of the U.S. population, if only because our participants shared the common characteristic of being willing to participate in survey research. As a result, we acknowledge that the specific estimates and associations we identified may not fully generalize to all real-world medication discussions. The higher health literacy and better health of our sample compared to the general older adult population makes some of our findings even more surprising as an educated sample is likely to be more aware of the risks of COVID-19 exposure, yet were often still willing to go to the pharmacy and did not appear to be sensitive to the presence of risk factors in their decision making. Finally, we gathered this information near the beginning of the COVID-19 pandemic.

Further research is needed to determine if older adults change their preferences for obtaining medications as the pandemic persists and impacts local communities to varying degrees.

Early in the COVID-19 pandemic, many older adults have been instructed to shelter in place, but only 12% had attempted to obtain extra medications. Over one-half of older adults reported that they would continue to go to the pharmacy to obtain their medications, even if they had additional health risk factors for serious illness from COVID-19. Women and the oldest participants were more likely to seek delivery of medications. Restricting medications was most common for two symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizingminimizing preferences) were associated with such decisions. Research is needed to identify strategies to encourage older adults to maintain a continuous supply of their medications while minimizing risk of exposure to COVID-19. This survey will take about 10 minutes. Your name will not be recorded anywhere in this survey. All of your answers will be completely anonymous. You may choose not to answer any questions you don't want to answer. If for some reason you cannot complete the survey, you may restart the survey at a later time by clicking on the survey link you were provided by Dynata. You will have to restart the survey from the beginning.

Your help means a lot to us. We thank you again for taking the time to complete this survey!

We would first like to share some information with you about COVID-19, which is a new disease. While our understanding of this disease is constantly changing, the following points are all generally agreed upon:

• COVID-19 is spread between people who are in close contact with one another (less than 6 feet away from each other). • COVID-19 is likely spreads when an infected person coughs or sneezes. These droplets land in the mouths or noses of people who are nearby and possibly can be inhaled into the lungs. • COVID-19 may also be spread to a person if they touch a surface or object that has the virus on it and then touch their own mouth, nose, or possibly their eyes. This is not thought to be the main way the virus spreads. • People are thought to be most contagious when they have symptoms (are the sickest), but it does appear that people can spread the disease even before they have symptoms.

• About 80 out of every 100 people who get COVID-19 have only mild or moderate symptoms • About 20 out of every 100 people get severe cases requiring hospitalization.

• While estimates vary, about 1 to 5 people out of every 100 who get COVID-19 die from the disease. • Older adults and people with serious chronic medical conditions like heart disease, diabetes, and lung disease are at much higher risk for serious illness and death from COVID-19.

We would now like you to imagine a scenario related to COVID-19. We recognize that you may or may not be in this situation right now. However, please imagine the scenario and what you would do to the best of your ability.

We would like you to imagine that there have been reports of COVID-19 in your local community. In other words, in your city, town, or county. Now imagine that government authorities have asked the public in your local community to shelter in place. This means that you should stay home and not leave unless necessary. However, trips to a grocery store are still allowed, as food is a necessity.

Imagine also that pharmacies continue to be open in your community. Going to the pharmacy to get your medications is one of the approved reasons to leave your home.

Hypothetical scenario -Medications part 1

Next, we would like you to imagine that you are taking different types of medications and that you are about to run out of that medication. For each medication we ask you about, we will provide a description and information about why they are commonly used.

We would like you to imagine that have been taking each medication for a long time but that you only have three days of medication remaining.

Please treat each medication separately. That means that you should imagine having three days remaining for that one medication while imagining that you continue to have a sufficient amount of all of your other medications.

What we want to know is: If you were running short on this one particular medication, what would you do? Your options will be:

• Go to the pharmacy to obtain your medication. This means that you would personally go to the pharmacy in person, potentially exposing yourself to COVID-19. • Decrease the amount of medications that you are taking to make it last longer. This could include taking a smaller amount of the medication or not taking the medication each time you normally take the medication. This would mean getting less of the benefit of the medication, at least until it runs out. • Ask someone else to deliver the medication to you. This means that you would stay at home, but that you might be exposed to COVID-19 by the person delivering the medications. It also means that the other person might become infected with COVID-19 because they did this delivery for you. • Stop the medication for now. This would mean no longer getting the benefit of the medication.

You could decide to restart the medication when it is safer to go get the medicine from the pharmacy.

Once again, we realize you may not be in this actual situation. Please imagine being in this situation to the best of your ability. 

Coronavirus: Resources, updates, and what you should know

COVID-19): Older adults

COVID-19): Getting ready for COVID-19

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Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effect of anxiety and depression on patient adherence

Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus

Depression and medication adherence in the treatment of chronic diseases in the United States: A meta-analysis

The 'cost' of medication nonadherence: Consequences we cannot afford to accept

Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD

Adherence and health care costs

Qualtrics: The Experience Management Platform

Mortality prediction with a single general self-rated health question: A meta-analysis

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Brief report: Screening items to identify patients with limited health literacy skills

Development of the medical maximizer-minimizer scale

Medical maximizing-minimizing preferences predict responses to information about prostate-specific antigen screening

A randomized study of patient risk perception for incidental renal findings on diagnostic imaging tests

Medical maximizing-minimizing predicts patient preferences for high-and low-benefit care

Eliciting medical maximizing-minimizing preferences with a single question: development and validation of the MM1

The beliefs about medicines questionnaire (BMQ): The development and evaluation of a new method for assessing the cognitive representation of medication

Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness

Explaining patients' beliefs about the necessity and harmfulness of antidepressants

Beliefs about medicines are strongly associated with medication-use patterns among the general population

Development and validation of the revised patients' attitudes towards deprescribing (rPATD) questionnaire: Versions for older adults and caregivers

Characteristics of older adults predict concern about stopping medications

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F2019-ncov%2Fhealthcare-resources%2Fpharmacies.html. Accessed 4

UPS will start delivering CVS prescriptions by drone in Florida -Here's how it works

Mobile fact sheet

Tech adoption climbs among older adults. Pew Research Center

Accessed 4

week? Prescription medications Over-the-counter medications or herbal/natural supplements Have you attempted to obtain extra prescription medications due to COVID-19?

Earlier in the survey, you answered questions about several medications. We would like to learn whether you currently or have ever taken these types of medications

For each type of medication, please indicate if you currently, in the past, or never have taken the medication

Antidepressants such as bupropion (Wellbutrin), citalopram (Celexa), duloxetine (Cymbalta), fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor)

Inhalers such as albuterol (ProAir, Proventil, Ventolin), albuterol/ipratropium (Combivent), budesonide/formoterol (Symbicort), fluticasone (Flovent), fluticasone/salmeterol (Advair), tiotropium (Spiriva) Insulin such as Humalog, Novolog, Humulin N or R, Novolin N or R, Lantus or Levemir Prescription pain medications such as tramadol (Ultram), fentanyl (Abstral, Actiq, Duragesic or Fentora), or morphine

Sleep medications such as eszopiclone (Lunesta), trazodone (Desyrel), or zolpidem (Ambien)

Statins or cholesterol medications such as atorvastatin (Lipitor), pravastatin (Pravachol), rosuvastatin (Crestor), or simvastatin (Zocor)

In general, how would you rate your health today? [poor/fair/good/very good/ excellent] Do you currently have any of the following conditions? (randomized order) • Lung disease

• Heart disease, such as abnormal heart rhythms, blood clots in your legs, an enlarged heart, or hardening or narrowing of your arteries

Are you currently immunocompromised, such as due to medications or having a transplant? Have you ever had a heart attack, stroke, mini-stroke

Do you smoke or use e-cigarettes (also known as vaping)? [yes, currently/ in the past /no, never] Other Scales -Medical Maximizer-Minimizer (MM1)

We would like to learn more about your approach to health care. Please rate how much you personally agree or disagree with the following statement. There is no right or wrong answer

Sometimes medical action is clearly necessary, and sometimes it is clearly NOT necessary. Other times, reasonable people differ in their beliefs about whether medical action is needed

to lean towards taking action or do you lean towards waiting and seeing if action is needed? Importantly, there is no "right" way to be. Please answer on the 1-6 scale below: • I strongly lean toward waiting and seeing • I lean toward waiting and seeing • I somewhat lean toward waiting and seeing • I somewhat lean toward taking action • I lean toward taking action • I

Please rate how much you personally agree or disagree with each statement. There are no right or

• My life would be impossible without my medicines. • Without my medicines, I would be very sick. • My health, at present, depends on my medications. • My medicines protect me from being worse. • My health in the future will depend on my medicines

BMQ Specific concern • I sometimes worry about the long-term effects of my medicines. • Having to take medicines worries me

• I sometimes worry about becoming too dependent on my medicines. • My medicines disrupt my life. • My medicines are a mystery to me

If my doctors had more time with patients, they would prescribe fewer medicines. 2. Doctors use too many medicines

Doctors place too much trust in medicines. 4. Natural remedies are safer than medicines. 5. Medicines do more harm than good

People who take medicines should stop their treatment for a while every now and then. 7. Most medicines are addictive

All medicines are poisons

Demographics What is your gender? [male / female / transgender / other] How many years old are you? __________ What is your race? Select all that apply. • American Indian or Alaska Native • Asian or Asian American • Black or African American • Native Hawaiian or Other Pacific Islander • White or Caucasian • Other (please specify): __________ completed? • None • Elementary school • Some high school, but no diploma • High school (Diploma or GED) • Trade school • Some college, but no degree • Associate's degree (AA, AS, etc.) • Bachelor's degree (BS

Professional degree (PhD, MD, etc.) thank you for taking the time to complete our survey

Appendix B. Demographic, personal health, and psychological factors that predict older adult's intention to restrict medications or have medications delivered compared to going to the pharmacy