Medication Adherence Robert DiGregorio, PharmD, FNAP, BCACP Professor (Long Island University) Sr. Director, Pharmacy & Pharmacotherapy Services (TBHC) Chief, Pharmacotherapy Department of Internal Medicine (TBHC)
Medications and Chronic Disease State Management For diabetes, hypercholesterolemia, and hypertension, a high level of medication adherence has been associated with lower disease-related medical costs Higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence For all four conditions, hospitalization rates were significantly lower for patients with high medication adherence
Medication Non-Adherence Patients can be reluctant to tell you that they don t take their medicines If you don t have a true picture of a patient s medication-taking behavior, you may needlessly escalate his or her treatment, resulting in potential harm to the patient, unnecessary work for the practice and increased costs overall
Magnitude of the Problem Data show about one-quarter of new prescriptions are never filled Patients do not take their medications about half of the time Most non-adherence is intentional patients make a rational decision not to take their medicine based on their knowledge, experience and beliefs
Eight Reasons that Patients are Non- Adherent 1. Fear. Patients may be frightened of potential side effects. 2. Cost. Patients may not fill medications in the first place or ration what they do fill to extend their supply. 3. Misunderstanding. Patients may not understand the need for the medicine, the nature of the side effects or the time it will take to see results. 4. Too many medications. 5. Lack of symptoms. 6. Worry. Concerns about becoming dependent on a medicine also lead to non-adherence. 7. Depression. Patients who are depressed are less likely to take their medications as prescribed. 8. Mistrust. Patients may be suspicious of their doctor s motives for prescribing certain medications because of recent news coverage of marketing efforts by pharmaceutical companies influencing physician prescribing patterns.
Adverse Events with Medications Adverse drug events account for over 100,000 deaths per year and are the 4th leading cause of death in the US. Medication errors exceed 2.7 million a year and cost our health care system over $177 billion Implementing a system where pharmacists are more involved in the management of patients has been shown to significantly improve the quality of care as well as costs www.ashp.org/s_ashp/docs/files/about/cdtm.doc http://open.nysenate.gov/legislation/bill/s2985-2011 www.nyschp.org/associations/8780/files/nyschp%20mos%20cdtm.pdf
Collaborative Drug Therapy Management (CDTM) American College of Clinical Pharmacy (ACCP) a collaborative practice agreement between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility for performing patient assessment; ordering drug therapy-related laboratory test; administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens. www.accp.com/docs/positions/positionstatements/pos2309.pdf
CDTM Improves The Quality Of Health Care In the literature Improved patient glycemic control Consistent and significantly greater reduction in 24-hour blood pressure and overall rate of blood pressure control (versus physician management) Subjects under the care of the physician-pharmacist team was more effective in helping patients reach their target lipid levels Carter BL, Ernst ME, Sezate GS, Weber CA, Zheng S. Pharmacist-physician comanagement of hypertension and reduction in 24- hour ambulatory blood pressures. Arch Intern Med. 2010 Oct 11; 170(18): 1634-9. Chau ACY, Fan CSY, Lee VWY, Li AWM. Clinical impact of a pharmacist-physician co-managed program on hyperlipidemia management in Hong Kong. Journal of Clinical Therapeutics. 2009 Aug 1; 34(4): 407-414 Dombrowski R, Haines ST, Leon N, Rochester CD. Collaborative drug therapy management for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. 2010 Jan 1; 67(1):42-8
Outpatient CDTM Pharmacy Services HIV Primary Care Anticoagulation Asthma Adult Pediatric Diabetes Adult Pediatric Hypertension Heart Failure Smoking Cessation Transitions of Care/Medical Home Bariatrics/Weight Loss
Surrogate Markers of Adherence Asthma/Pediatric Asthma Clinics Reduced need for SABA Reduction in Emergency Visits Smoking Cessation Clinics Six month quit rate Heart Failure Clinic Re-admission rate Lipid Clinic Achievement of target levels Diabetes Clinic Achievement of target HbA1C levels
Quality & Adherence: Anticoagulation Clinic 80 70 60 50 40 30 20 10 0 TTR TIME IN THE THERAPEUTIC RANGE Time in the Therapeutic Range is a quality measure for assessing the efficacy of oral vitamin K antagonist anticoagulants (warfarin) INR can vary based on dietary intake of vitamin K-rich foods, drug interactions, and medication adherence TBHC NATIONAL
Healthfirst Initiatives at TBHC 2015 Initiatives Calling patients 65-79% adherent to medications Education of providers regarding Pharmacotherapy Clinics AllScripts Sunrise Clinical Manager 6.1: Meds from Other Sources
Healthfirst Initiatives at TBHC 2016/2017 Initiatives Deploying two additional Pharmacotherapy Specialists dedicated to improving adherence through our Pharmacotherapy Clinics and telephone follow-up Expanding Saturday Clinic hours in Family Medicine Implementation of Annual Wellness Visits with medication adherence discussion Deploying a Medication Adherence Coordinator to contact patients and pharmacies to facilitate refills and deliveries
Calling Patients 65-79% Adherent to Medications Each patient was called at least once Half of the patients were unable to be reached for various reasons. inability to leave a voicemail incorrect phone number inability to communicate with non-english speaking patients Half of patients most frequently reported one of the following reasons for non-adherence: the medication(s) listed on the adherence list had been recently changed by their PCP the medication had been recently filled at their respective pharmacy and was not reflected on the adherence list the patient needed medication refills If the pharmacy students identified patients who had questions about their medications, such as indication, dosing, name, etc., the students were instructed to provide the ambulatory care pharmacotherapy specialist s clinic phone number to make an appointment
Provider Education In-service update regarding the available pharmacotherapy clinics was delivered to physicians in both the Internal Medicine and Family Medicine departments Physicians were educated to refer patients who had polypharmacy, needed medication management, or had uncontrolled medicationmanaged chronic conditions The electronic medical record at The Brooklyn Hospital Center was updated to include pharmacotherapy consults to improve and facilitate the process of referring patients to these clinics Providers were educated and motivated to write 90-day prescriptions for their patients to improve patient adherence. Writing 90-day prescriptions vs. 30-day prescriptions decreases patient trips to the pharmacy
Pharmacotherapy Clinic Referral Pharmacotherapy Specialists were able to identify reasons for non-adherence, perform medication reconciliation, and discontinue any medications that were unnecessary for each patient The number one reason for patients non-adherence was recognized to be lack of understanding for their medical condition and being unfamiliar with why the medication was prescribed Through education and empathy, patients were more adherent and were better controlled with their medical conditions
Meds from Other Sources The function of Meds From Other Sources in the electronic medical record was made clear to other attending physicians, providers, medical residents, and pharmacists. Allows providers and other healthcare professionals to access insurance claims of patients, providing information such as last date filled, quantity, and name of pharmacy where filled Prompts conversation with patients regarding adherence, verifies which medication the pharmacy filled, and shows if the patient is filling medications at multiple pharmacies
Contact Information Robert DiGregorio, PharmD, FNAP, BCACP Professor (Long Island University) Sr. Director, Pharmacy & Pharmacotherapy Services (TBHC) Chief, Pharmacotherapy Department of Internal Medicine (TBHC) The Brooklyn Hospital Center Phone: (718) 250-8182 Email: rdigregorio@tbh.org