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April 2011 · Vol. 60, No. 4 Suppl:

 

Improving Medication Adherence in Chronic Disease Management


FACULTY — Stephen A. Brunton, MD, FAAFP

Adjunct Clinical Professor of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Executive Vice President for Education, Primary Care Education Consortium
Dr. Brunton disclosed that he had no conflict of interest relevant to this program.

  Barriers to medication adherence

As revealed in an online survey of primary care clinicians conducted by the Primary Care Education Consortium (PCEC) (Appendix), there are a variety of barriers to medication adherence, which can be categorized as patient-, medication-, or clinician-related. The most important clinician-related barriers identified by survey respondents—poor communication/relationship with patients, and lack of time for adherence counseling—are supported by reports in the literature that indicate significant unmet needs among patients for information about the purpose for and the risks, benefits, dosing, and administration of their medications, and inconsistency among health care providers in communicating this type of information.1,2 In a chart-based review of pharmacologic quality indicators in a national sample of 3457 adult patients, participants received only 62% of recommended pharmacologic care overall; performance was lowest for patient education and documentation (46%).3 Another clinician-related barrier that may contribute to medication nonadherence is a lack of appreciation for cultural or religious issues that may affect patients’ beliefs and decisions regarding their condition and/or the proposed treatment and impede clinician-patient communication.4 Clinician-patient communication may also be hampered by a clinician’s failure to provide information (oral and/or written) at a level appropriate for patient understanding (eg, using nonmedical language, materials written at the 4th grade level, visual aids).4

Among patient factors identified in studies and surveys, including the aforementioned online survey, as negatively affecting medication adherence, the most common include functional health literacy (a patient’s capacity to obtain, process, and understand basic health information needed to make appropriate health decisions as determined by comprehension of written health care materials) and numeracy (ability to understand and act on numerical health care instructions); the quality of the clinician-patient relationship; beliefs about their condition; beliefs about the need for a medication and its effectiveness and safety/tolerability; the presence of multiple comorbidities; the need for multiple medications and complex medication regimens; forgetfulness; advanced age; lack of medication information; and the provision of medical care by multiple clinicians.5-12 A survey of 18,000 older adults showed that 12% did not fill a prescription because of a belief that the medication was unnecessary. In addition, nearly 20% skipped doses or stopped taking the medication because they believed the medication made the condition worse.12

Respondents to the PCEC online survey also identified complex treatment regimens that do not fit a patient’s particular situation as an important medication-related factor impeding medication adherence. This observation was confirmed by the survey of 18,000 older adults, of whom 46% took 5 or more prescriptions and 54% had more than 1 prescriber. Among those with 3 or more chronic health conditions, 52% did not take all their medications as prescribed.12 Respondents of the online survey identified out-of-pocket medication cost as another important medication-related barrier to adherence; several studies and a literature review confirm this finding.9,13,14 Patients appear to selectively forgo medications because of cost; however, those decisions are often influenced by factors that are not cost-related (eg, patient beliefs about medications, satisfaction with medication-related information, depressed mood, and quality of the clinician-patient relationship).7,9,12,13 It is important to note that cognitive, physical, and visual challenges can also hinder the ability of patients, especially older patients, to take their medicines correctly.2

A little-appreciated category of barriers to adherence is the health care system at large. The health care system in the United States is not currently designed to allow for patient education, empowerment, goal setting, and behavior change and, as such, lacks the proper incentives, protocols, and support mechanisms to improve patients’ medication adherence.15,16 However, a clinically sound medication adherence program with a committed effort from all health care stakeholders could result in significant savings, as well as improvement in health. These findings were demonstrated by a recent study of diabetes patients which showed that for every additional $1 spent on medication, there was a savings of $7 in medical costs.16

  The role of health care teams in promoting medication adherence

Other members of a patient’s health care team, including community pharmacists, case managers, and nurses, can also play significant roles in promoting medication adherence and can be especially helpful in a number of situations. Examples of these situations include when patients receive care from several clinicians for multiple comorbidities or have particularly complex treatment regimens, and would benefit from a thorough medication review and development of solutions to adherence problems. A community pharmacist may have more frequent opportunities than a clinician to screen for appropriate medication use and to work with the patient and clinician to address adherence issues.17,18 Similarly, the increased frequency of contact by phone or in person between a patient and a case manager affords repeat opportunities for the case manager to review medications and adherence patterns, and to provide positive feedback and reinforcement or to identify and address barriers to adherence. Staff nurses can also play a vital role by providing patient education and ensuring a patient’s understanding of his or her treatment plan.19,20

Several online resources offer provider resources and patient education materials to support medication adherence:

  1. National Consumers League: http://www.nclnet.org/health/106-prescription-drugs/234-ncls-medication-adherence-campaign

  2. North Carolina Alliance for Healthy Communities: http://www.ncahc.org/med_adherence/

  3. New York City Department of Health and Mental Hygiene: http://www.ci.nyc.ny.us/html/doh//////html/csi/csi-medication-adherence.shtml

  4. National Council on Patient Information and Education (NCPIE): http://www.talkaboutrx.org/med_compliance.jsp

Case examples of multifaceted interventions to promote medication adherence

Population/Duration of Intervention Intervention Adherence Measures and Results Clinical Outcome Measures and Results
Asthma (N=207; n=103 in program ≥1 year)21
Duration of intervention: 5 years

  • 1:1 asthma education by certified asthma educator x 1-2 sessions

  • Visit q3 months w/pharmacist case manager: medication use, symptom frequency and triggers, inhaler technique, spirometry/peak flow results assessed

  • Action plan reviewed/updated

  • Medication use assessed by case manager at regular visits

    –Spending on asthma medications increased

    –Asthma-related medical claims decreased

  • Percentage of patients with ED visits decreased from 9.9% annually for the 3 years prior to program enrollment to 1.3% in the 4 years after program initiation; similarly, hospitalizations decreased from 4% annually to 1.9%

  • Change in NAEPP asthma severity classification from baseline: 55% of patients improved, 37% had no change, 8% were worse

  • Average FEV1 improved from 81% to 90%; proportion of patients with normal FEV1 improved from 50% at enrollment to 75% after ≥1 year
Hypertension (N=883; intervention group, n=423; control group, n=460)22
Duration of intervention: 6 months, then follow-up for up to 5 years (mean 39 months)

  • Counting of pills during physician visits (1, 2, 3, and 6 months after study initiation)

  • Designation of a family member to support adherence behavior

  • Provision of an information sheet at start of intervention, to be brought to each visit (included medication information; questions about problems taking the medication or side effects since last visit; space to record BP readings)

  • Encouragement to self-measure BP every other week

  • Intervention physicians underwent initial 2-hour training session on motivational interviewing techniques

  • Medication adherence over first 6 months of follow-up (percentage of days on which correct number of doses was taken):

    –92% (intervention) vs 89% (control), P=.002

  • SBP and DBP at end of first 6 months of follow-up (intervention vs control):

    –SBP 149 vs 151 mm Hg; (P=.008)

    –DBP 82 vs 83 mm Hg (P=.013)

    –Between-group differences of ≈2 mm Hg in SBP persisted over the 5 years of follow-up; DBP difference between groups was <1 mm Hg after 18 months of follow-up

  • Exploratory outcome: composite end point of all-cause mortality and hospital admission for any CV event at 5 years of follow-up:

    –16% vs 19% event rate (P=NS after adjustment for DBP, age, sex, self-reported adherence, CV risk profile)
Hyperlipidemia (N=355 new statin users; no prescription for statin in past 12 months)23
Duration of intervention: 4 months

  • Intervention group identified from national pharmacy claims database; control group of similar patients not exposed to the intervention

  • Patient survey to assess attitudes and beliefs related to CV disease and cholesterol management

  • Heart Health Counts (HHC) patient education program, designed to increase clarity in the CV risk dialogue between physician and patient.

  • HHC physician counseling kit included:

    –Set of 1-minute health manager patient education tools to describe cholesterol risks

    –Patient contracts/pledges designed to confirm patient commitment to prescribed regimen

    –Copy of NCEP pocket guidelines

    –Chart stickers

  • Following office visit, patient received 5 HHC mailings over a 4-month period focusing on various aspects of CV health and risk

  • Data derived from national pharmacy claims database to calculate:

    –Average number of days of new prescriptions filled for statin during 120-day study period: mean, 12.4 more days vs control group; P=.01

    –Percentage of patients who filled prescriptions for 120 days of statin therapy: 67.8% vs 57.8% control group; P<.01)

  • Data not reported

  • Of 164 physicians who used the HHC counseling kits and returned surveys:

    –93% said the kits were easy to use

    –88% said the kits allowed them to clearly explain CV risk factors to their patients

    –62% said the kits helped their patients make positive lifestyle changes
Patients ≥65 years taking ≥4 chronic medications (N=200; 81% and 92% treated for hyperlipidemia or hypertension, respectively)24
Duration of intervention: 12 months

  • Comprehensive pharmacy care program:

    –Individualized medication education; medications dispensed in blister packs; follow-up with clinical pharmacist every 2 months

  • Pills counted at follow-up visits

  • Adherence:

    –Baseline: 61%

    –6 months: 97%

    –12 months: 95% for those continuing comprehensive care vs 69% for those randomized back to usual care (P<.001)

  • SBP (mmHg):

    –Baseline: 133

    –6 months: 130

    –12 months: 124 for those continuing comprehensive care vs 133 for those randomized back to usual care (P=.005)

  • LDL-C (mg/dL):

    –Baseline: 92

    6 months: 87

    –12 months: 88 for those continuing comprehensive care vs 88 for those randomized back to usual care (P=NS)
BP=blood pressure; CV=cardiovascular; DBP=diastolic blood pressure; ED=emergency department; FEV1=forced expiratory volume in 1 second; NAEPP=National Asthma Education and Prevention Program; NCEP=National Cholesterol Education Program; SBP=systolic blood pressure.

  Appendix. Primary Care Education Consortium online primary care survey on medication adherence

On January 22, 2010, the Primary Care Education Consortium (PCEC) distributed an online survey to 153 members of the Journal of Family Practice Honorary Advisory Panel and 1500 members of the PCEC Primary Care Metabolic Group (PCMG) on the topic of medication adherence. Complete surveys were received from 244 persons, for a 14.8% response rate.

Key findings of the survey:

Cost of treatment or lack of insurance was the greatest barrier listed; however, when asked what 1 tool or resource respondents would like for improving patient adherence, the top 3 tools all related to more time for or better tools for communication with the patient. Lower costs were the 4th most requested resource. Respondents had tried many strategies to improve patient adherence, and the results below indicate how effective they believe their efforts to date had been:

  • 63.7% of respondents believed their current strategies to improve patient-related barriers had been effective to highly effective

    • Only 19.1% believed these strategies had been very to highly effective

  • 60.1% of respondents believed their current strategies to improve medication-related barriers had been effective to highly effective

    • Only 17.5% believed these strategies had been very to highly effective

  • 65.8% of respondents believed their current strategies to improve clinician-related barriers had been effective to highly effective

    • Only 25.3% believed these strategies have been very to highly effective

    References

  1. Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166:1855–1862.
  2. Gordon K, Smith F, Dhillon S. Effective chronic disease management: patients’ perspectives on medication-related problems. Patient Educ Couns. 2007;65:407–415.
  3. Shrank WH, Asch SM, Adams J, et al. The quality of pharmacologic care for adults in the United States. Med Care. 2006;44:936–945.
  4. Oyekan E, Nimalasuriya A, Martin J, et al. The B-SMART appropriate medication-use process: a guide for clinicians to help patients—part 1: barriers, solutions, and motivation. Perm J. 2009;13:62–69. http://xnet.kp.org/permanentejournal/winter09/pdfs/B-SMART.pdf.  Accessed September 7, 2010.
  5. McHorney CA, Gadkari AS. Individual patients hold different beliefs to prescription medications to which they persist vs nonpersist and persist vs nonfulfill. Patient Prefer Adherence. 2010;4:187–195.
  6. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.
  7. Piette JD, Heisler M, Krein S, et al. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med. 2005;165:1749–1755.
  8. Matheus M. In-depth telephone interviews of health care practitioners concerning prescription medication adherence. Conducted September 17, 2009. Oakton, VA: Matheus Marketing, LLC.
  9. Kurlander JE, Kerr EA, Krein S, et al. Cost-related nonadherence to medications among patients with diabetes and chronic pain: factors beyond finances. Diabetes Care. 2009;32:2143–2148.
  10. Brown C, Battista DR, Bruehlman R, et al. Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Med Care. 2005;43:1203–1207.
  11. Hauber AB, Mohamed AF, Johnson  FR, Falvey H, et al. Treatment preferences and medication adherence of people with Type 2 diabetes using oral glucose-lowering agents. Diabet Med. 2009;26:416–424.
  12. Safran DG, Neuman P, Schoen C, et al. Prescription drug coverage and seniors: findings from a 2003 national survey. Health Aff (Millwood). 2005;suppl Web exclusives:W5–152-W5-166.
  13. Briesacher BA, Gurwitz JH, Soumerai SB. Patients at-risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med. 2007;22:864–871.
  14. Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291:2344–2350.
  15. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–497.
  16. Teare SD. Medication adherence: America’s new drug problem? The Healthcare Savings Chronicle. 2008;5. http://www.imakenews.com/seroper/e_article001121994.cfm?x=b11,0,w.   Accessed December 9, 2010.
  17. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “There’s got to be a happy medium.” JAMA. 2010;304:1592–1601.
  18. Oyekan E, Nimalasuriya A, Martin J, et al. The B-SMART appropriate medication-use process: a guide for clinicians to help patients—part 2: adherence, relationships, and triage. Perm J. 2009;13:50–54. http://www.thepermanentejournal.org/files/Fall2009PDFS/TheB-SMARTAppropriateMedicationUseProcessAGuide.pdf.   Accessed September 7, 2010.
  19. Cutrona SL, Choudhry NK, Stedman M, et al. Physician effectiveness in interventions to improve cardiovascular medication adherence: a systematic review. J Gen Intern Med. 2010;25:1090–1096.
  20. Albert NM. Improving medication adherence in chronic cardiovascular disease. Crit Care Nurse. 2008;28:54–65.
  21. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc (2003). 2006;46:133–147.
  22. Pladevall M, Brotons C, Gabriel R, et al. Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study). Circulation. 2010;122:1183–1191.
  23. Casebeer L, Huber C, Bennett N, et al. Improving the physician-patient cardiovascular risk dialogue to improve statin adherence. BMC Fam Pract. 2009;10:48.
  24. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006;296:2563–2571.

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