Strategies to Improve Medication Adherence It Can Be SIMPLE Shane Greene, Pharm.D. Director of Pharmacy Services Care N Care Insurance Company, Inc. Objectives Pharmacists: Identify predictors of medication nonadherence. Describe the provider s role in medication adherence it s really quite SIMPLE. Apply SIMPLE targeted questions to patient interactions to improve medication adherence. Pharmacy Technicians: Identify the five interacting dimension of adherence. Identify predictors of medication nonadherence. Describe the role pharmacy technician s play in improving patient adherence to medications. Adherence Defined The extent to which a person s behavior taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health care provider Sabate E, ed. World Health Organization; 2003. 1
Is Adherence Important? Treatment Outcomes Brown MT, Bussell JK. Mayo Clin Proc. 2011;86(4):304 314. Is Adherence Important? Treatment Adherence Outcomes Brown MT, Bussell JK. Mayo Clin Proc. 2011;86(4):304 314. CMS Part D STAR Ratings Adherence 2017 STAR Cut Points for MAPD Measure 1 STAR 2 STAR 3 STAR 4 STAR 5 STAR Adherence for DM <70% 70 75% 76 78% 79 82% 83% Medications Adherence for HTN <71% 71 74% 75 78% 79 82% 83% (RAS Antagonists) Adherence for Cholesterol (Statins) <66% 66 72% 73 76% 77 81% 82% MAPD = Medicare Advantage with Part D Plan CMS Fact Sheet 2017 Star Ratings. https://www.cms.gov/medicare/prescription Drug Coverage/PrescriptionDrugCovGenIn/PerformanceData.html Accessed on 4/15/17. 2
QUESTION For MAPD Plans, what is the CMS average STAR rating in 2017 for medication adherence for cholesterol (Statin use)? A. 1 STAR B. 2 STAR C. 3 STAR D. 4 STAR E. 5 STAR CMS Part D STAR Ratings Adherence Average STAR Rating for MAPD Plans Measure 2014 2015 2016 2017 Adherence for DM Medications 3.7 3.1 4.1 4.0 Adherence for HTN (RAS Antagonists) 3.7 3.1 4.1 4.0 Adherence for Cholesterol (Statins) 3.6 3.3 4.0 3.5 All are triple weighted measures CMS adjusts the cut points yearly Rates are lower for Part D Plans only MAPD = Medicare Advantage with Part D Plan CMS Fact Sheet 2017 Star Ratings. https://www.cms.gov/medicare/prescription Drug Coverage/PrescriptionDrugCovGenIn/PerformanceData.html Accessed on 4/15/17. QUESTION According to a 2010 National Association of Chain Drug Stores report, what percent of prescriptions written are actually taken properly? A. 15% B. 25% C. 45% D. 55% E. 75% 3
Written Prescription vs Actual Use. National Association of Chain Drug Stores, Pharmacies: Improving Health, Reducing Costs, July 2010. Based on IMS Health data Why is medication adherence so hard to achieve? Five Interacting Dimensions of Adherence 4
Five Interacting Dimensions of Adherence SE FACTORS Limited English Low health literacy Lack of support Homelessness Lack of insurance Medication cost Cultural beliefs Five Interacting Dimensions of Adherence THERAPY FACTORS Complex regimen Complex technique Duration of therapy Frequent changes Side effects Social stigma Five Interacting Dimensions of Adherence PATIENT FACTORS(Physical) Visual/hearing/cognitive impairment Impaired mobility/dexterity Swallowing problems PATIENT FACTORS (Psyc/Behav) Knowledge of disease/why need Perceived benefit/adv effects Attitude/motivation/dependence 5
Five Interacting Dimensions of Adherence COND. FACTORS Chronic condition Lack of symptoms Severe symptoms Depression Psychotic d/o Develop. disability Five Interacting Dimensions of Adherence HCT FACTORS Prov pt relationship Communication Health beliefs differ Education materials Knowl of adherence Long wait times Cont. of care Five Interacting Dimensions of Adherence HCT FACTORS Prov pt relationship Communication Health beliefs differ Education materials Knowl of adherence Long wait times Cont. of care COND. FACTORS Chronic condition Lack of symptoms Severe symptoms Depression Psychotic d/o Develop. disability PATIENT FACTORS(Physical) Visual/hearing/cognitive impairment Impaired mobility/dexterity Swallowing problems PATIENT FACTORS (Psyc/Behav) Knowledge of disease/why need Perceived benefit/adv effects Attitude/motivation/dependence SE FACTORS Limited English Low health literacy Lack of support Homelessness Lack of insurance Medication cost Cultural beliefs THERAPY FACTORS Complex regimen Complex technique Duration of therapy Frequent changes Side effects Social stigma 6
QUESTION All of the following are health team related factors that influence medication adherence EXCEPT: A. Provider patient relationship B. Medication cost C. Long wait times D. Communication skills QUESTION Which of the following is a predictor of medication nonadherence? A. English language proficiency B. Higher cognitive function C. Fear of medication side effects D. Keeping medical appointments Predictors of Nonadherence Low literacy/limited English language proficiency Homelessness Depression Psychiatric disease Substance abuse Lower cognitive function or cognitive impairment Forgetfulness Anger, psychological stress, anxiety Lack of insight into illness Lack of belief in benefit of treatment Belief medications are not important or are harmful Complexity of medication regimen Tired of taking medications Inconvenience of medication regimen Side effects or fear of medication side effects Cost of medication, copayment, or both Barriers to access to care or medications Inadequate follow up or discharge planning Missed appointments 7
Achieving medication adherence is complex, but it doesn t have to be difficult! Provider Strategies to Improve Adherence S implify regimen I mpart knowledge M odify patient beliefs and human behavior P rovide communication and trust L eave the bias E valuate adherence Simplify the regimen Adjust timing, frequency, amount, and dosage. Match regimen to patients activities of daily living. Recommend all medications be taken at same time of day Avoid prescribing medications with special requirements Investigate customized packing Adjust the treatment to the patient versus the patient to the treatment 8
Simplify the regimen Investigate customized packing Example DISCLAIMER: This is NOT an endorsement for PillPack. I do not receive any form of payment or perks from PillPack. https://www.pillpack.com/ Simplify the regimen Adjust timing, frequency, amount, and dosage. Match regimen to patients activities of daily living. Recommend all medications be taken at same time of day Avoid prescribing medications with special requirements Investigate customized packing Adjust the treatment to the patient versus the patient to the treatment Simplify the regimen Adjust timing, frequency, amount, and dosage. Match regimen to patients activities of daily living. Recommend all medications be taken at same time of day Avoid prescribing medications with special requirements Investigate customized packing adjst tx 2 pt vs pt 2 tx #happypharmacist #healthypatient 9
Simplify the regimen Provider/Patient Conversations Adjust timing, frequency, amount, and dosage. You need two different medications to control your condition. I can prescribe two different pills or one pill that is a combination product. The combination product will most likely cost more. Which option would best suit your needs? Match regimen to patients activities of daily living. In order for this medication to work effectively, you will need to take this medication twice a day. Can you take it at breakfast and dinner to help you remember or is there a more convenient time? Recommend all medications be taken at same time of day Tell me about all the pills you take and let s determine together if you could take them all in the morning. Impart knowledge Provider/Patient Conversations Focus on patient provider shared decision making Encourage discussions Provide clear instructions Involve family and friends Provide quality web sites Suggest computerized self instruction Provide concrete advice for how to cope with medication costs Reinforce all discussions often Impart knowledge Provide clear instruction Pictograms http://www.usp.org/audiences/consumers/pictograms/form.html 10
Impart knowledge Provider/Patient Conversations Focus on patient provider shared decision making It s important to take this medication every day. However, if the cost imposes a financial hardship on you, please let me know right away and we can look at other options. Encourage discussions Here is your prescription and here are written directions. Take two pills twice a day. In starting this new regimen, how will you incorporate these medications into your daily routine? Involve family and friends It can sometimes be difficult to remember to take all of your medications. Is it possible to ask your wife to help you remember to take this medication? Modify patient beliefs and human behavior Empower patients to self manage their condition Ensure patients understand the risk of nonadherence Ask patients to describe nonadherence consequences Address fears and concerns Provide rewards for adherence Modify patient beliefs and human behavior Provider/Patient Conversations Ask patients to describe nonadherence consequences Can you tell me what you think will happen if you stop taking your medication? Address fears and concerns Do you have any fears or concerns about the medication I have prescribed? 11
Provide communication and trust Improve interviewing skills Practice active listening Provide emotional support Provide clear, direct, and thorough information Elicit patient s input in treatment decisions Allow adequate time for patients to ask questions Build trust Provide communication and trust Communication is Critical If a physician communicates poorly: 19% higher risk of nonadherence If a physician communicates well: Odds of patient adherence are 2.26 times higher More than 183 million medical visits avoided Haskard Zolnierek KB, DiMatteo. Physician communication and patient adherence to treatment: a meta analysis. Med Care. 2009; 47(8): 826 834. Provide communication and trust Improve interviewing skills Practice active listening Provide emotional support Provide clear, direct, and thorough information Elicit patient s input in treatment decisions Allow adequate time for patients to ask questions Build trust 12
Provide communication and trust Practice active listening Confirm patient message Accurately paraphrase patient remarks Use verbal and nonverbal cues showing understanding and empathy Give feedback to the patient during the discussion Further the dialogue to get more information Watch for acceptance or reluctance Provide communication and trust Elicit patient s input in treatment decisions I prefer to make the final selection about which treatment I receive. I prefer to make the final selection of my treatment after seriously considering my doctor s opinion. I prefer that my doctor and I share responsibility for deciding which treatment is best for me. I prefer that my doctor make the final decision about which treatment will be used, but seriously considers my opinion. I prefer to leave all decisions regarding my treatment to my doctor. Degner LF, Sloan JA. Decision making during serious illness: what role do patients really want to play? J Clin Epidemiol.1992; 45:941 950. Provide communication and trust Allow adequate time for patients to ask questions Create a safe environment to talk openly Use lay language, not medical jargon Sit down to achieve eye level Use pictograms Allow patient to write down instructions Ask patients to teach back the instructions 13
Provide communication and trust Build Trust Do you need to improve your level of trust? SCALE: 1 to 5 (1 = strongly disagree; 5 = strongly agree) I feel my patients can tell me anything and I don t judge them or cut them off The majority of my patients trust my judgment about their medical care I know the costs of the medications I prescribe and consider cost as a factor in decision making I do not withhold bad news from my patients, minimize their situation, or condone (ignore) bad health behaviors If I make a mistake in treatment, I do not try to hide it from my patient A higher score indicates a higher trust level Provide communication and trust Provider/Patient Conversations Improve interviewing skills/active listening So what I hear you saying is that your stomach hurts only at night. You told me about the hot flashes and the frequent night sweats; now tell me how often this is bothering you. Hmm, I hear you, but I want to know more. Can you describe yesterday s symptoms? Provide emotional support I can see that you are in pain; it must be very uncomfortable. Elicit patient s input in treatment decisions It appears like you are uncomfortable with my suggestion. What part of this plan doesn t work for you? Leave the bias Know the overall demographics of a patient population Learn some Spanish Specifically ask about attitudes, beliefs and cultural norms about medication Tailor education to the patient s level of understanding Learn more about low health literacy and how it affects patient outcomes 14
Leave the bias Provider/Patient Conversations Specifically ask about attitudes, beliefs and cultural norms about medication I m interested in what your family thinks about you having to take 3 new medications. Can you tell me? Tailor education to the patient s level of understanding OR Learn more about low health literacy and how it affects patient outcomes Let s play a game. I m going to point to one of these pills and I want you to tell me what time of day you take it. Evaluating adherence Just ask Evaluate at each encounter Identify barriers Pill counting or drug levels Review medication containers occasionally Evaluating adherence Approaches to measuring adherence Subjective Measurements Asking patients, family members, caregivers, and physicians/providers Objective Measurements Counting pills, examining refill records, or electronic medication event monitoring systems Biochemical Measurements Drug levels or adding a nontoxic marker to the medication Brown MT, Bussell JK. Mayo Clin Proc. 2011;86(4):304 314. 15
Evaluating adherence Calculating adherence objectively Pill Counting x 100 80% PDC (using prescription claim data) # # x 100 80% Summary Is Adherence Important? YES!!! Improving medication adherence is critical to patient outcomes Achieving medication adherence is complex Multiple patient internal and external factors involved Improving medication adherence is a continual process, but It can be SIMPLE Treatment Adherence Outcomes Brown MT, Bussell JK. Mayo Clin Proc. 2011;86(4):304 314. QUESTION Strategies to improve medication adherence include all of the following EXCEPT: A. Modify patient beliefs B. Evaluate adherence C. Impart knowledge D. Prescribe complex medication regimens 16
Provider Strategies to Improve Adherence S implify regimen I mpart knowledge M odify patient beliefs and human behavior P rovide communication and trust L eave the bias E valuate adherence Questions? 17