The Science of Medication Adherence P R E S E N T E D T O L E A D I N G A G E W A S H I N G T O N J U N E 6 TH,

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1 The Science of Medication Adherence P R E S E N T E D T O L E A D I N G A G E W A S H I N G T O N J U N E 6 TH,

2 Why are we talking about adherence? Nonadherence Waste $258.3 Billion 62% Adherence Hospitals on the hook for 90-day post care outcomes Sicker patients in lower levels of care Independent Living Home Health 2011 Express Scripts Drug Trend Report, USA Today, NY Times, Dallas Morning News. The Oregonian

3 Elements of Adherence Filling and refilling prescriptions on time Taking medication on schedule or as prescribed Taking medication for the duration prescribed 3

4 Our Discussion Arc How do we measure adherence? An explanation of Medication Possession Ratio Does adherence matter? We think so, but what does the research show? What are the causes of non-adherence? Can can we increase it? How? Strategies to raise adherence 4

5 Measuring Adherence 5 N I C O L L E K I N G D E E R I N G, R. P H, C G P D I R E C T O R O F C L I N I C A L S E R V I C E S

6 Adherence Measurement Options Drug claims data Efficient and generally accurate Interviews Generally not accurate but efficient Surveys Accurate but labor-intensive Pill Counts Accurate but labor-intensive and burdensome Drug Assays Not practical for most drugs 6 Source: David Nau, PhD, RPh, CPHQ

7 Medication Possession Ratio (MPR) MPR=The sum of days supply for all pills in a period divided by the number of days in the period Simple to calculate Used in the greatest number of studies If a patient has 30 daily pills in a 60 day period, their MPR is 50% 7 Sum of days supply for all fills in a period Number of days in a period

8 Does Adherence Matter? 8

9 Roebuck MC et.al. : Impact of Medication Adherence on Health Care Cost Savings Design: Retrospective study of integrated pharmacy and medical claims Study Population: 135,000 patients with at least 2 outpatient visits on different days, or 1 hospitalization, or 1 emergency department visit with 1 or more of the following conditions : congestive heart failure, hypertension, diabetes, dyslipidemia and with a MPR < 0.8. Method: 6 Months - Baseline MPR Checkpoints at Year 1, Year 2, Year 3 MPR with Condition-Level Adherence Measured by annual pharmacy, medical and total health care spend 9

10 Results Medication Adherence decreased hospital days ranging by days Drug costs increased Reduced net yearly medical costs $7,827 for congestive heart failure, $3908 in hypertension, $3,756 diabetes and $1,258 dyslipidemia 10

11 Adherence Matters 11

12 What causes nonadherence? 12

13 Causes of Non-Adherence? Cost Don t think they need it/don t feel sick Patient feels better Don t understand what the drug is for Side effects Confusing directions Complexity Timing: empty or sometime full stomach Taking multiple times a day Several monthly visits to pharmacy Using multiple pharmacies Forgetfulness Forget to take Forget to refill 13

14 How Do We Increase Adherence? 14 P R O V E N S T R A T E G I E S

15 Problem: Regimen Complexity Timing: empty or sometime full stomach Taking multiple times a day Several monthly visits to pharmacy Using multiple pharmacies 15

16 Proof: Patient Confusion 16

17 Choudhry NK et.al : The Implications of Therapeutic Complexity (TC) on Adherence to Cardiovascular Medications 17 Design: Retrospective study of claims data in patients prescribed cardiovascular medications Study Population: 1.8 million patients on statins and ACE/ARB Method: 3 Months - Baseline Therapeutic Complexity: number of medications, prescribers, pharmacies, pharmacy visits, refill consolidation. 1 Year Post-Baseline Complexity: Medication Adherence was measured during months 4 thru 15, The relationship between complexity and adherence was assessed using multivariable linear regression. Results: MPR Statin 68.6%, ACE/ARB 66.4%

18 Results 18 Greater prescribing and filling complexity was associated with lower levels of adherence. Patients with the least refill consolidation had adherence rates that were 8% lower over the subsequent year than patients with the greatest refill consolidation Conclusion: Strategies to reduce this complexity may help improve medication adherence.

19 Solution: Simplify 19

20 Schneider, P.J. et.al.: Impact of Medication Packaging on Adherence and Treatment Outcomes Design: Randomized controlled trial Study Population: 85 patients age >/= 65 years old with essential hypertension treated with lisinopril from three ambulatory care clinics Intervention: Daily-dose blister packaging (Pill Calendar) versus traditional bottle of loose tablets. Method: Baseline and 6 and 12 month physician visit for blood pressure evaluation with every 28 day visits to the pharmacy Measurement: prescription refill regularity, medication possession ratio (MPR) and diastolic blood pressure 20 Schneider, PJ, Murphy JE, Pedersen,CA. J Am Pharm Assoc 2008;48:58-63

21 21 Results: Patient receiving daily-dose blister packaging Refilled their prescription on time more often (P =0.01) Had higher MPRs (P= 0.04) Lower diastolic blood pressure P = 0.01 Than those using traditional bottles of loose tablets. Conclusion: Daily-dose blister packaging contributed to the likelihood of refilling prescriptions on time, a higher MPR, and lower diastolic blood pressure.

22 Lee et.al.: Effect of Comprehensive Pharmacy Care (CPC) on Adherence 1 Design: Multiphase, prospective, randomized controlled trial Study Population: 200 community-based patients >/= 65 years old taking at least 4 chronic medications, receiving care at a military hospital and its affiliated retirement home. Intervention: Individualized education, adherence packs, pharmacist follow-up Method: 2 month baseline Phase 1: 6 months CPC intervention Phase 2: 6 months continued CPC vs. return to Usual Care Results: Phase 1: CPC intervention increased adherence from 61.2% to 96.9%, with reductions in systolic bp and LDL-C Phase 2: High adherence (95.5%) persisted with continued CPC, but was lost (69.1%) in subjects switched to Usual Care Conclusions A pharmacy care program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP 1. Lee JK, Grace KA, Taylor AJ. JAMA. 2006; 296:

23 Results: Phase 1: 23 CPC intervention increased adherence from 61.2% to 96.9% Reductions in systolic bp and LDL-C Phase 2: High adherence (95.5%) persisted with continued CPC Lost (69.1%) in subjects switched to Usual Care Conclusion: A comprehensive pharmacy care (CPC) program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP

24 How Do We Increase Adherence? 24 UN- P R O V E N S T R A T E G I E S

25 Cost Cost is not a key driver g/ Doughnut hole going away in 2014 Pill splitting 25

26 Change Patient Behavior 26

27 Technology Can Help 27

28 Refill Synchronization Reduce the number of trips to the pharmacy All maintenance drugs are filled at once Simplify My Meds NASPA Program 28

29 Text messages s Phone calls Glow caps Forgetfulness 29

30 Equipment Mechanical Dispensing Medi-Sets Blister/bubble pack Salad pack 30

31 Good Internet Sites