Medication Adherence:

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1 By: Sarah Kelling PharmD, MPH, BCACP Clinical Assistant Professor University of Michigan College of Pharmacy Sarah Kelling is currently a Clinical Assistant Professor at the University of Michigan College of Pharmacy. Her practice interests include developing innovative clinical pharmacy services in the outpatient setting, increasing access to outpatient clinical pharmacy services, and medication therapy management. She currently teaches a Community Pharmacy course for first year pharmacy students and precepts Advanced Pharmacy Practice Experience students. Dr. Kelling reports no actual or potential conflicts of interest in relation to this continuing pharmacy education activity. Medication adherence is a complicated and important aspect of achieving quality health and medication related outcomes in patients. The prevalence and impact of non-adherence and that increase the risk of non-adherence are discussed in this CPE activity, in order for pharmacy technicians to have the tools to positively impact medication adherence among patients. Upon completion of this activity, Pharmacy Technicians will be able to: 1. Define medication adherence 2. Describe the prevalence and impact of non-adherence 3. Summarize the that increase the risk of non-adherence 4. Discuss strategies to identify nonadherence among patients 5. Identify opportunities for pharmacy technicians to support pharmacists and patients in order to promote medication adherence CPE Information: UAN #: H04-T CEUs/Hours: 1 contact hour (0.1 CEU) Target Audience: Pharmacy Technicians Activity Type: Knowledge-based Initial Release Date: 1/1/2015 Planned Expiration Date: 1/1/2018 The Collaborative Education Institute is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity has been developed specifically for pharmacy technicians and is one of 10 activities in the TEAM series. Medication Adherence: Opportunities for Pharmacy Technicians Introduction Approximately 50% of patients with chronic conditions do not take their medications as prescribed. 1 This has been linked with issues such as worsening illness, increased rates of hospitalization, increased health care costs and death. 2,3 Approximately 125,000 preventable deaths occur every year in the United States due to medication non-adherence. 4 According to the World Health Organization (WHO), adherence is defined as the extent to which a person s behavior taking a medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider. 1 It is important to note that adherence involves patients actively participating in their health care decisions alongside members of their health care team. For this reason, adherence is somewhat different than compliance, which refers to a patient passively following the directions of a health care professional. 5 There is an increased emphasis being placed on medication adherence. For example, Medicare Part D insurance plans receive star ratings based on their performance. Plans have an incentive to receive all five stars as patients are only allowed to change plans during an annual open-enrollment period,unless they are switching into a five-star rated plan. Plans are graded on a variety of, including those related to medication use. For example, the focus areas in 2014 included decreasing the number of elderly patients on high-risk medications (e.g., medications that could increase the risk of falls); ensuring patients were on the appropriate medications if they were diagnosed with diabetes; and increasing medication adherence, specifically for patients taking certain diabetes medications, high blood pressure medications, or cholesterol medications. While there are a small number of focus areas, insurance plans care about these areas as each item is worth three times the points of most other items. 6,7 Types of medication non-adherence Medication non-adherence can involve several different types of issues, including overuse, underuse and inappropriate administration or technique. For example, suppose a patient comes to the pharmacy every week to purchase a prescription migraine medication when the medication is only supposed to be used a few times every month. This is an example of overuse of medication. Another common example of medication overuse occurs when a patient is not experiencing relief from their prescription pain medication and therefore, takes either more medication at once or perhaps takes the medication more frequently than prescribed. The pharmacist can help to create a plan to decrease the overuse of medication, often in conjunction with the patient s prescriber. Medication underuse occurs when a patient takes less medication than prescribed. For example, if a patient experiences side effects from the medication, he may decide to take one-half tablet instead of a whole tablet every day. Patients 2015 TEAM SERIES 1

2 The Use of Over-The-Counter Drugs During Pregnancy who cannot afford medications may decide to take the medication every other day instead of daily. Or, if patients do not believe that the medication is beneficial, they may decide to take the medication only when they are feeling poorly, even if the medication is supposed to be used on a regular basis. Finally, patients may experience medication non-adherence by inappropriately administering the medication. This is common with medications that require special devices, such as inhalers or insulin pens or vials. If a patient does not know how to use the device, it is difficult for the patient to take the medication as prescribed. Table 1: Dimensions affecting medication adherence 1 Dimension Conditionrelated Health care team and systemrelated Patientrelated Social and economic Therapyrelated Examples Availability of effective treatments Co-morbid conditions, such as depression or drug and alcohol abuse Level of disability (physical, psychological, social, and vocational) Patient perceptions of disease and treatment Rate of progression and severity of disease Severity of symptoms Lack of insurance reimbursement Lack of knowledge and training for health care providers managing chronic diseases Lack of patient education and follow up Poor medication distribution systems Short visits between patients and health Attitudes Beliefs Expectations Knowledge Perceptions Resources Beliefs about illness and treatment High cost of medication High cost of transportation Lack of social support Long distance from treatment center Low health literacy Low level of education Low socioeconomic status Unemployment Unstable living conditions Availability of support Complexity of the medical regimen Duration of treatment Frequent changes in treatment Immediacy of beneficial effects Previous treatment failures Side effects Factors that impact adherence There are many reasons why a patient may be non-adherent to a medication regimen. The WHO has identified five dimensions that impact adherence: (1) social and economic ; (2) health care team and system-related ; (3) condition-related ; (4) therapy-related ; and (5) patient-related. 1 Please refer to Table 1 for examples for each of these dimensions. In order to better understand what each of these terms mean, consider the case below. C.J. is a 52-year-old male patient who has diabetes, high blood pressure and pain in his left knee. He pays cash for his medication regimen that includes metformin 1000 mg twice daily, insulin glargine 30 units subcutaneously every night at bedtime, lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, rosuvastatin 10 mg daily and gabapentin 300 mg three times daily. He does not currently have a vehicle and reports that the public transportation is not reliable, so he walks to his job four days per week and the pharmacy three times per month, although that is growing increasingly difficult due to shooting pain in his feet and legs. He notes that he is receiving fewer hours at work and he is worried about paying his bills. He mentions being frustrated that his next doctor s appointment is a month away, even though he was recently in the hospital due to his uncontrolled diabetes and some of his medications have changed. As C.J. is telling you this information, you look at his prescription profile and notice that he is typically late refilling his prescriptions; therefore, you believe he may have a problem with medication adherence. There are multiple reasons that C.J. may be non-adherent with his medication regimen. For example, social and economic include being underemployed and the high cost of several brand name medications (insulin glargine and rosuvastatin). Health care team and system-related could include lack of health insurance and a medication distribution system that prevents him from refilling all of his medications at one time each month. Uncontrolled diabetes that is resulting in worsening nerve pain is an example of a condition-related factor that can impact adherence. Therapyrelated include having to take medications multiple times every day and frequent changes in treatment. Finally, patient-related include his beliefs about his illnesses and his expectations about his treatment plan. Strategies to identify non-adherence Multiple strategies can be used to identify patients who may not be adherent with their treatment regimen. Depending on the setting, the pharmacy technician may have access to some or all of the following resources. In the community pharmacy setting, a common strategy to identify potential medication non-adherence is to review a patient s medication profile. The medication profile typically 2015 TEAM SERIES 2

3 contains information such as the patient s name, address, phone number, allergies and a record of each medication that has been filled. Table 2 includes an example of a patient s medication dispensing record. Information that should be reviewed includes when the medication was filled and how many days the medication should last. For example, sertraline was filled for 30 days on 9/28, which means that the patient should have finished the medication on 10/28. However, she did not refill the medication until 11/1 (4 days late). Subsequently, there were 43 days between the refills on 11/1 and 12/14. There are multiple limitations to relying on medication dispensing records. For example, there may be valid reasons why a patient may pick up a medication early or late, such as the doctor increasing or decreasing the dose, respectively. If a patient purchases a medication at a different pharmacy, the refill will not be reflected in the dispensing record. Table 2: Example medication dispensing record Medication Name & Strength Sertraline 25 mg Sertraline 25 mg Sertraline 25 mg Directions Qty DS Date Take 1 tablet by mouth daily Take 1 tablet by mouth daily Take 1 tablet by mouth daily / / /28 If a pharmacy technician is working in an ambulatory care setting, medical records are likely available. The medical record typically includes a section related to current and previous medications. Depending on the facility, over-thecounter medications and herbal supplements may be included in addition to prescription medications. While the medication dispensing information is likely not available, the medical records can provide valuable information about how the patient is supposed to take their medications, particularly if there have been changes since the last prescriptions were written (e.g., decrease dose to one-half tablet daily). Additionally, according to one study, 28.3% of new prescriptions are never filled, thus they would not appear on a medication dispensing record. 8 A newer strategy that can be used to identify potential medication non-adherence is by partnering with an online medication therapy management (MTM) platform. MTM has been defined as a distinct service or group of services that optimize therapeutic outcomes for individual patients. 9 Companies such as Mirixa and OutcomesMTM work with health insurance plans to identify patients who may benefit from MTM services. The information is shared with the pharmacy or pharmacist so that the patient can be contacted regarding a comprehensive medication review (CMR) or targeted intervention. CMRs involve a pharmacist or other trained health care professional discussing each medication with the patient or caregiver and assessing the medication therapy to make sure that the medication is appropriate to treat a patient s condition, is likely to be effective, safe and to identify any problems with adherence. 10 Targeted interventions focus on a specific problem, such as a gap in therapy (e.g., the patient does not seem to be prescribed a medication that is consider part of the standard of care for a particular disease state) or the patient appears to not be taking a medication as prescribed. This is identified using claims data that is submitted by the pharmacy when a prescription is filled. Regardless of which method is used to identify potential medication non-adherence, it is important to talk with the patient or caregiver in order to identify if medication non-adherence is actually a problem. If so, it is key then to understand the underlying cause. There are a variety of reasons that a patient may appear to be non-adherent according to prescription claims, when in fact the patient is taking the medication appropriately. For example, the medication regimen may have changed (medication discontinued, or the dose increased or decreased), the medication may be prescribed only as needed, the patient may have been hospitalized, or the doctor s office may have provided samples. In each of these cases, the importance of medication adherence can continue to be reinforced. Additionally, it is possible that the patient will appear adherent to a medication regimen when in fact the patient is not taking the medication as prescribed. For example, a patient may sometimes forget to take a dose of medication and then take two doses the next time he remembers. Another common scenario is when the patient purchases a medication at the pharmacy on a regular basis (such as when medications are automatically refilled) and then fails to take the medication as prescribed. It might be helpful to use a standardized tool to assess adherence, such as the Morisky Medication Adherence Scale, which requires that patients answer either four or eight questions regarding their medication-taking behavior. 11 An alternative tool is the Adherence Estimator, which uses three questions to help assess a patient s beliefs and ability to afford his or her medications. 12 Finally, recent research has supported use of the question over the last 7 days, how many days were you able to take your (specific) medicine exactly as prescribed? 13 If medication non-adherence is identified, understanding the cause of the non-adherence will allow the pharmacist to make a recommendation about strategies to increase adherence. While an in-depth discussion regarding strategies to overcome non-adherence is outside of the scope of this article, several examples include providing education about the importance of the medication therapy, suggesting or providing a reminder system such as a pill box, helping the patient identify a common time to take the medication every day that aligns with an activity that the patient already completes (such as taking morning doses of medication directly after brushing one s teeth), asking the patient to demonstrate how they will use a device or 2015 TEAM SERIES 3

4 describe how they will take a medication and communicating adverse reactions to the prescriber. A useful resource to learn more about strategies to overcome non-adherence is the evidence-based website 14 Opportunities for pharmacy technicians A number of opportunities exist for pharmacy technicians to help support medication adherence among patients. Pharmacy technicians may interact more frequently with patients than pharmacists interact with patients. Depending on the setting, it may be appropriate for the pharmacy technician to help identify patients with potential medication non-adherence issues, such as by using the strategies described above. Depending on the policies and procedures of the worksite, as well as state laws, pharmacy technicians can begin to collect data from patients. The type of information that is collected will be based on the type of encounter the pharmacy technician and pharmacist have with the patient. For example, if a patient is purchasing a medication refill, recognizing potential medication nonadherence, such as by identifying that the patient is always late to refill his or her medications, may allow the pharmacist to intervene before the patient leaves. Some patients are more comfortable sharing personal information, such as worries about the cost of medications, with the pharmacy technician. This information can be shared with the pharmacist in a professional and discrete manner so that the pharmacist can help identify if potential solutions to the problem underlying the medication non-adherence exist. opportunity to promote medication adherence. Having an understanding of the types of non-adherence, the that increase the likelihood of non-adherence and strategies to identify non-adherence, allows pharmacy technicians to support patients and pharmacists as they seek to improve medication use. A pharmacy technician who works at a location that is providing MTM services may have an expanded role. It is common for online MTM platforms to identify potential medication non-adherence using claims data. This information is shared with the pharmacy so that a staff member can reach out to the patient to help encourage medication adherence. Potential opportunities for pharmacy technicians include adding notes into the pharmacy computer system to flag patients who appear to be nonadherent according to the MTM platform, starting to compile data from the medication dispensing records and the MTM platform, documenting the encounter that the pharmacist had with the patient and billing for the service. 15 It is important for pharmacy technicians to recognize that certain roles are most appropriate for the pharmacist to complete. Pharmacists should provide oversight to pharmacy technicians and be available to answer questions. Additionally, a licensed pharmacist should make recommendations to patients or health care providers regarding medication or lifestyle changes. Conclusion Medication non-adherence impacts approximately one-half of patients with chronic conditions, leading to worse health outcomes, increased costs and premature deaths. Pharmacy technicians working in a wide variety of settings have the Pharmacy 2015 TEAM SERIES Series 4 4

5 REFERENCES: 1. World Health Organization. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization, Chisholm-Burns MA, Spivey CA. The cost of medication nonadherence: consequences we cannot afford to accept. J Am Pharm Assoc (2003). 2012;52(6): Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353: National Council on Patient Information and Education. (2013). Accelerating progress in prescription medicine adherence: The adherence action agenda. A National Action Plan to Address America s Other Drug Problem Goud E, Mitty E. Medication adherence is a partnership, medication compliance is not. Assisted Living Column. Geriatric Nursing. 2010;31(4): Medicare 2014 part C & D star ratings technical notes. Centers for Medicare and Medicaid Services. Retrieved from media/1741/2014_cms_tech_notes_2013_09_27final. pdf. 11 June Medicare part C & D star ratings: Update for Centers for Medicare and Medicaid Services. Retrieved fromhttp:// Coverage/PrescriptionDrugCovGenIn/Downloads/2014U sercallslidesplanpreviews.pdf. 11 June Fischer MA, et al. Primary medication non-adherence: Analysis of 195,930 electronic prescriptions. J Gen Intern Med 2010;25(4): Medication therapy management in pharmacy practice: Core elements of an MTM service model version 2.0. American Pharmacists Association and National Association of Chain Drug Stores. Retrieved from elements_of_an_mtm_practice.pdf. 10. Cipolle RJ, Strand L, Morley P. (2012). Pharmaceutical care practice: The patient centered approach to medication management. 3 rd ed. New York: The McGraw- Hill Companies, Inc. 11. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986; Adherence estimator. Retrieved from adherenceestimator.com/default.aspx. 27 October Unni EJ, Olson JL, Farris KB. Revision and validation of medication adherence reasons scale (MAR-Scale). Curr Med Res Opin 2014:30: Adult meducation: Improving medication adherence in older adults. Retrieved from 8 October Bright DB, Powers MF, Kelling SE, Mihalopoulos C. Involvement of pharmacy technicians in medication therapy management workflow. Ohio Pharmacist. 2013;62(1) TEAM SERIES 5

6 POST ASSESSMENT QUESTIONS: 1. According to the World Health Organization, which of the following are included in the definition of adherence? A. Taking a medication B. Following a diet C. Executing lifestyle changes D. All of the above Refer to the following case to answer questions 2-3. M.S. is a 54-year-old male who was recently prescribed simvastatin to help lower his risk of having a heart attack. He heard that this medication might cause side effects like muscle pain; therefore, he has not started to take the medication. 2. Approximately what percent of prescription are never filled for the first time? A. 20% B. 30% C. 40% D. 50% 3 Which of the following best represents the reason that M.S. is not taking simvastatin? A. Condition-related factor B. Health care system related factor C. Social and economic factor D. Therapy-related factor complete and not a pharmacy technician? A. Collect preliminary data from a patient profile B. Complete documentation for the service C. Prepare billing documents after a patient encounter D. Recommend change of therapy to a physician 7. Which of the following is an example of a social and economic factor that may increase the likelihood that a patient is non-adherent to a medication regimen? A. A medication is only available as a brand name product and is expensive B. A medication dose is changed very frequently by the physician C. A patient does not feel any symptoms when blood pressure is running high D. A patient has depression which makes it more difficult to control her diabetes Refer to the following case to answer questions 8-9. Jacob Johnson is a 26-year-old male who was diagnosed with asthma two months ago after presenting to the local emergency department with shortness of breath. He was given prescriptions for fluticasone/salmeterol diskus and albuterol HFA and told to follow up with his primary care doctor. He comes into the pharmacy looking for a refill on the albuterol HFA prescription and becomes agitated when you inform him that there are no refills. 4. Which of the following resources can be used to identify potential medication non-adherence, regardless of the setting that the pharmacy technician is employed? A. Review the medication dispensing record B. Review the patient s medical record C. Talk with the patient or caregiver D. Use a medication therapy management platform 5. T.J. was recently prescribed an albuterol inhaler to treat her shortness of breath. The prescription states that she can take up to 2 puffs every 6 hours as needed. Based on these directions, the inhaler should last for 25 days. However, she runs out of medication 16 days after it was filled. Which of the terms best describe the type of nonadherence that T.J. is experiencing? A. Compliance B. Diversion C. Overuse D. Underuse 6. Which of the following activities related to medication non-adherence is most appropriate for a pharmacist to 8. According to the medication dispensing record, Jacob should have run out of this fluticasone/salmeterol diskus inhaler approximately one month ago. Which of the terms best describe the type of non-adherence that T.J. is experiencing? A. Abuse B. Overuse C. Underuse D. Jacob is not experience non-adherence 9. Which of the following is an example of a health care team and system-related factor that may be contributing to Jacob s non-adherence with his fluticasone/salmeterol diskus inhaler? A. There was a lack of education about how and when to use the inhaler. B. The cost of the medication is too high without any insurance coverage. C. The patient did not have a primary care physician to follow up with. D. All of the above 2015 TEAM SERIES 6

7 10. A pharmacy technician is tasked with supporting a pharmacist who runs a medication adherence program in a community pharmacy. How might the pharmacy technician help the pharmacist identify patients who are at risk for medication non-adherence? A. Add a note onto patient profiles if the patient appears to be non-adherent according to the online medication therapy management program the pharmacy uses. B. Announce over the store loudspeakers Our pharmacist can help you create a plan for your medications even if you want to stop them all. C. Ask every patient who drops off a prescription Are you non-adherent with your medications? D. Post a sign that says Non-adherent to your therapy? Consult the pharmacist on duty today. CPE Instructions: 1. Go to click on Technician tab 2. Scroll down to Pharmacy TEAM Series 2015 and click on Register and Log-In (if this is your first time in CEI s website you will need to set up a quick profile by clicking New To CEI ) 3. Click on the box to select the TEAM Series 2015 and click Register 4. On the Payment Transaction Page, scroll down to Pay With An Access Code and type in the access code given to you by your association and click Continue 5. You can now start the TEAM Series right away by clicking Click Here to Go to Activity. Scroll down to activity and all 10 TEAM articles are within your profile! 6. Whenever you want to go back in and complete a TEAM Series activity, go to Log-In, and click on your Profile. Any questions, please contact Cindy Smith at csmith@gotocei.org or TEAM SERIES 7