Multidisciplinary and Pharmacy-Based Strategies for Improving Medication Adherence

MEDICATION NONADHERENCE has been documented since ancient times, when Hippocrates wrote, “Keep watch also on the faults of the patients which often make them lie about the taking of things prescribed.”

Unfortunately, nonadherence continues to this day. As the late great Surgeon General C. Everett Koop, MD, said, “Drugs don’t work in patients who don’t take them.”

Today, with an estimated 50% to 66% of patients failing to take medication as prescribed, with 17% of the United States gross domestic product spent on health care, and with 75% of those costs related to chronic condition management medication, nonadherence is a larger problem than ever.1-3

Low adherence rates are the cause of 33% to 69% of medication-related hospitalizations. In patients with hypertension alone, nonadherence is responsible for approximately 86,000 premature deaths in the United States every year. The annual economic costs of medication nonadherence are estimated at $100 billion, and according to statistics from the Network For Excellence In Health Innovation, the cost of avoidable drug-related problems, including nonadherence, costs society approximately $290 billion each year.4-7

The costs of nonadherence rapidly diminish as adherence improves. For instance, in patients with diabetes, each 10% increase in medication possession ratio rates reduces overall health care costs by 9% to 29%.

In fact, for the most adherent patients with diabetes, medical costs are halved versus the least adherent patients ($8867 vs $4570). Similarly, in a 2000 study of a Medicare population with multiple chronic disease states, for each additional prescription filled, hospital-related costs fell by $104 per patient, or approximately 5% overall.8-11

Several methods have been proposed for improving adherence including12,13:
  • Reducing medication co-pays
  • Introducing a lottery to award patients who are adherent to medication
  • Sending patients information about the importance of taking medication
  • Using medication therapy interventions and pharmacist-directed counseling sessions
  • Correcting certain beliefs about medications 
For instance, in patients with diabetes, certain erroneous beliefs were associated with less consistent medication use.

These misconceptions about medications include statements like14:
  • “I only have diabetes when my blood sugar is high.”
  • “The symptoms of diabetes are minimal.”
  • “I am worried about becoming addicted to medications.”
  • “I am worried about the side effects of medications.” 
Ultimately, education is the key to improving adherence. For managed care plans, investing in medication adherence initiatives is a winning proposition.

It has been estimated that for every dollar spent on medication adherence initiatives for patients with diabetes, $7 in health care costs are saved (Figure 1).



By some estimates, improved adherence in patients with diabetes alone could save $8.3 billion per year.8-11

Given that physicians have little time with patients and that pharmacists are the most accessible health care providers, improving adherence is an important opportunity for pharmacists to improve patient outcomes. Many studies show the value of pharmacists in improving patient outcomes through adherence-promoting initiatives.

For instance:
  • In the Asheville project, pharmacist counseling of patients with type 2 diabetes reduced glycosylated hemoglobin levels, and low-density lipoprotein cholesterol levels, while saving $1200 to $1872 per patient per year.15
  • In patients receiving antiretroviral therapy, patients were nearly 3 times more likely to adhere to treatment if they received counseling from a pharmacist (odds ratio [OR] = 2.74, 95% CI = 2.44­-3.10). Counseling services reduced projected inpatient costs and services by more than $2000 per patient per year.16
  • One-on-one counseling (2 sessions over 6 months) with a pharmacist durably improved adherence in patients receiving medication for high cholesterol.17
  • A study of patients with Medicare insurance who received medication for chronic heart failure or chronic obstructive pulmonary disease (COPD) found that medication therapy management (MTM) improved adherence, reduced use of contraindicated medications in patients with congestive heart failure (18% to 30% in patients who did not receive MTM versus 16.8% of patients who received MTM), and reduced all-cause and COPD-related hospitalizations and emergency department visits in patients receiving counseling, resulting in $356 saved per member per month.18
Pharmacists use a variety of methods to promote adherence. In a 2011 survey of pharmacy managers at 162 health care organizations, interventions for improving adherence included individual coaching, medication reconciliation, MTM, telephonic reminders, postdischarge calls, and home visits, among others (Figure 2).19



Team care using the entire health care team has been demonstrated to improve adherence. For example, in a 12-month study, patients receiving team care experienced a nearly 3-fold increase in adherence among patients receiving insulin (P <.001), a near doubling in antihypertensive medication adherence (P <.001), a greater than 3-fold increase in blood pressure monitoring rates (P <.001), and a 28% increase in glucose monitoring rates (P = .006).20

Pharmacists can improve adherence in several ways, including through individualized coaching, refill reminders, and medication synchronization. In 2014, nearly three-fourths (74%) of independent community pharmacists offered MTM services, and approximately two-thirds (67%) offered programs to improve patient adherence.

As the pharmacy profession continues to evolve, pharmacists will become an increasingly important part of the move toward improving adherence by reducing regimen complexity for patients, correcting misconceptions, and ensuring that patients understand the benefits and risks of therapy.21 SPT

References
  1. World Bank. Health expenditure, total (% of GDP). http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. Accessed November 2015.
  2. Amara S, Adamson RT, Lew I, Slonim A. Accountable care organizations: impact on pharmacy. Hosp Pharm. 2014;49(3):253-259. doi: 10.1310/hpj4903-253.
  3. Manolakis PG, Skelton JB. Pharmacists' contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010;74(10):S7.
  4. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.
  5. Stafford RS, Bartholomew LK, Cushman WC, et al. Impact of the ALLHAT/JNC7 Dissemination Project on thiazide-type diuretic use. Arch Intern Med. 2010;170(10):851-858.
  6. Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Disord. 2006;6:48.
  7. New England Health Institute (NEHI). Thinking outside the pillbox. NEHI website. www.nehi.net/writable/publication_files/file/pa_issue_brief_final.pdf. Published August 2009. Accessed November 2015.
  8. Balkrishnan R, Rajagopalan R, Camacho FT, Huston SA, Murray FT, Anderson RT. Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25(11):2958-2971.
  9. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530.
  10. Jha AK, Aubert RE, Yao J, Teagarden JR, Epstein RS. Greater adherence to diabetes drugs is linked to less hospital use and could save nearly $5 billion annually. Health Aff (Millwood). 2012;31(8):1836-1846. doi: 10.1377/hlthaff.2011.1198.
  11. Stuart BC, Doshi JA, Terza JV. Assessing the impact of drug use on hospital costs. Health Serv Res. 2009;44(1):128-144. doi:  10.1111/j.1475-6773.2008.00897.x.
  12. UnitedHealthcare launches first diabetes plan with incentives for preventive care [news release]. www.enhancedonlinenews.com/portal/site/eon/permalink/?ndmViewId=news_view&newsId=20090115005315&newsLang=en&permalinkExtra=. Published January 15, 2009. Accessed November 2015.
  13. Belluck P. For forgetful, cash helps the medicine go down. The New York Times. www.nytimes.com/2010/06/14/health/14meds.html?pagewanted=all&_r=0. Published June 13, 2010. Accessed November 2015.
  14. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med. 2009;32(3):278-284.
  15. Cranor CW, Bunting BA, Christensen DB. The Asheville project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184.
  16. Hirsch JD, Gonzales M, Rosenquist A, Miller TA, Gilmer TP, Best BM. Antiretroviral therapy adherence, medication use, and health care costs during 3 years of a community pharmacy medication therapy management program for Medi-Cal beneficiaries with HIV/AIDS. J Manag Care Pharm. 2011;17(3):213-223.
  17. Taitel M, Jiang J, Rudkin K, Ewing S, Duncan I. The impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy. Patient Prefer Adherence. 2012;6:323-329. doi: 10.2147/PPA.S29353.
  18. Marrufo G, Dixit A, Perlroth D, Montesinos A, Rusev E, Packard M. Medication therapy management in a chronically ill population: interim report. http://innovation.cms.gov/Files/reports/MTM-Interim-Report-01-2013.pdf. Published June 2013. Accessed November 2015.
  19. Healthcare Intelligence Network. New chart: how a pharmacist helps to improve medication adherence. www.hin.com/chartoftheweek/pharmacist_improve_medication_adherence.html. Accessed November 2015.
  20. Lin EH, Von Korff M, Ciechanowski P, et al. Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial. Ann Fam Med. 2012;10(1):6-14. doi: 10.1370/afm.1343.
  21. NCPA digest: community pharmacists promoting medication adherence, generic drug savings [news release]. National Community Pharmacists Association website.www.ncpanet.org/newsroom/news-releases/2014/10/28/ncpa-digest-community-pharmacists-promoting-medication-adherence-generic-drug-savings. Accessed November 2015.



MICHAEL R. PAGE, PHARMD, RPH, earned his PharmD from the Ernest Mario School of Pharmacy at Rutgers University. He has worked as a community pharmacist at CVS Pharmacy and is currently clinical editor in clinical and scientific affairs at Pharmacy Times.




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