Medication Adherence: Strategies for Improving Outcomes Thursday, June 16, 2016, 12:00 p.m. to 1:00 p.m. Andrea H. Williams, RPh, MBA President, RX CONSULTANTS LLC, Wilmington, DE
EDUCATIONAL OBJECTIVES Review barriers to medication adherence Discuss motivational and behavioral interviewing Review medication adherence best practices Discuss strategies to improve medication adherence rates in the community pharmacy setting
DEFINITION
ADHERENCE AS DEFINED BY THE WORLD HEALTH ORGANIZATION The extent to which a person s behavior, including taking medication, following a diet, and/or executing lifestyle changes corresponds with recommendations from a healthcare provider.
ADHERENCE VERSUS COMPLIANCE ADHERENCE PATIENT-CENTERED COLLABORATION BETWEEN PATIENT AND HEALTH CARE PROVIDER COMPLIANCE HEALTH CARE PROVIDER-CENTERED DOMINATION BY HEALTH CARE PROVIDER EXCHANGE OF INFORMATION PATIENT ENGAGEMENT DISCUSS, NEGOTIATE DICTATE INFORMATION PATIENT PASSIVE PERSUADE, COERCE Source: Gould E, Mitty E. Medication adherence is a partnership, medication compliance is not. Geriatr Nurs. 2010; 31(4):290-98
PRIMARY VS. SECONDARY NON-ADHERENCE PRIMARY New Rx for new med statin as example* Approximately 1/5 of patients did not fill the initial Rx despite having Rx insurance Fear of side effects, etc., may be a more prominent reason in this setting SECONDARY Initial Rx filled Not refilled Not taken correctly Take, stop, take, stop Every other day Take when symptomatic Take 1/3 prescribed/day *Derose SF, Green K, Marrett E. Automated outreach to increase primary adherence to cholesterol-lowering medications [published online November 26, 2012].Arch Intern Med. 2013.
BACKGROUND
MEDICATION NON-ADHERENCE America s other drug problem * Major health care priority Pervasive problem worldwide Leads to disease progression, disease complications, absenteeism, decreased productivity Medication non-adherence results in 33 to 69 percent of medication related hospitalizations *Source: National Council on Patient Information and Education
PROBLEM Source: www.scriptyourlife.org
DIMENSIONS OF NON-ADHERENCE
MULTIFACTORIAL CAUSES OF MEDICATION NON-ADHERENCE Source: World Health Organization. Retrieved from http://www.who.int. SOURCE: WWW.ACPM.ORG
BARRIERS TO MEDICATION ADHERENCE
PATIENT-SOCIAL-ECONOMIC RELATED FACTORS Forgetfulness Low health literacy Perceptions about illness Prematurely discontinuing medications Social stigma Fear Media influence regarding safety risk Cultural beliefs Poverty High cost of medications Insurance
PRESCRIBER-RELATED FACTORS Time constraints Physician-patient relationship Communication between physicians and other healthcare providers
FIGURE 3 THERAPY-RELATED FACTORS Adherence to Medication According to Frequency of Dosing FIGURE 3: Mayo Clinic Proceedings 2011 86, 304-314DOI: (10.4065/mcp.2010.0575)
HEALTH SYSTEM Prescription drug costs Restrictive formulary Time constraints Transition of care services
MEDICATION ADHERENCE INTERVENTIONS
INTERVENTIONS SHOULD BE PATIENT-TAILORED Behavior-related Forgetfulness of patients Daily alerts 90-day medication supplies Automatic renewals Clinical Questions or concerns about medication Pharmacist consultation Linguistically and culturally appropriate Cost-related Payment assistance programs Lower cost medication alternatives Lower cost pharmacy option (e.g., home delivery)
CASE STUDY George Hill, a 80 year old male, is a new patient at your community pharmacy. His past medical history is significant and includes hypertension, depression, osteoarthritis, hypothyroidism, diabetes, erectile dysfunction and hyperlipidemia. Medications: lisinopril 20mg daily, HCTZ 25mg, metformin 500mg bid, simvastatin 40mg at bedtime, Lyrica 75mg daily, aspirin 81mg daily, levothyroxine 75mcg daily, Prozac 20mg daily, Cialis 2.5mg as directed, celecoxib 200mg daily, cinnamon capsules twice daily, ginger capsules daily, multivitamin daily.
PATIENT S COMMENTS I want generic medications. I do not have reliable transportation. I can t establish a medication taking routine. I feel overwhelmed. I do not understand the instructions on the label. Why do I need to take so many medications? My doctor did not have enough time during my last appointment with him to explain how I should take medications. I prefer herbal medicines.
MOTIVATIONAL INTERVIEWING GOAL: Change medication taking behavior EDUCATE * MOTIVATE*- remove barriers STEP 1: Resolve ambivalence about medication adherence Step 2: Increase motivation to take medication as prescribed
BEHAVIORAL INTERVIEWING TIPS Sample Questions to Ask Patient 1. What is your daily routine for taking your medications? 2. How do you organize your medications? 3. What happens to your medication administration plan if your daily routine changes? 4. How often do you miss a dose of your medications? 5. What are the barriers to you taking your medications as prescribed? 6. What will motivate you to take your medications daily as prescribed? 7. Explain to me how you should take each medication.
STRATEGIES TO IMPROVE MEDICATION ADHERENCE
DEVELOPING INDIVIDUALIZED MEDICATION ADHERENCE PLAN Ask open ended questions Listen attentively Assess patient s medication taking behaviors Assess health literacy Assess patient understanding of their illness Empathize Set goals and objectives
EFFECTIVE STRATEGIES FOR IMPROVING MEDICATION ADHERENCE Team-based care Pharmacist-led multicomponent interventions Education with behavioral support Pill counting Single dose vs. multiple dose prescribed Sources: Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57; Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012; 157(11):785-795.
HOW TO OVERCOME CHALLENGES OR BARRIERS Introduce team-based care Collaborate with pharmacists and/or nurses Educate patients on how to take medications Improve access and communication Offer patients the opportunity to contact the provider s office with any questions Use telemedicine, particularly in rural areas Use technologies and analytical services that facilitate measuring and improved adherence.
IMPROVING OUTCOMES
PROBLEM
MEDICATION ADHERENCE PERCENTAGE Goal: > 80% # of pills absent in time ( X ) x 100 # of pills prescribed for time ( X ) Source: Mayo Clinic. April 2011;86(4):304-314. Retrieved from www.mayoclinicproceedings.com.
MEDICATION ADHERENCE MEASUREMENTS Subjective Objective Biochemical
RESOURCES
mycvs On the Go Ease & Convenience Prescription Management: Manage all prescriptions from your account. ReadyFill : Refills ready when you need them. Refill Reminders: Get an e-mail when it s time to refill your prescriptions. 90-Day Prescriptions: Save time and money by filling a 90-day prescription Source: www.cvs.com
WALGREENS Convenience: Get easy access to face-to-face education and counseling in nearly 8,000 points of care, helping to improve prescription adherence particularly within the critical 30-day window of time. Collaboration: Work with physicians within hospitals and health system to follow up with patients beyond the hospital stay, ensuring that critical post-discharge orders are followed Community Reach: Help health systems, payers and providers cast a wide net in the community by offering education, awareness and patient interactions through our services, locations and clinical staff. Personal Service: Build strong personal relationships that encourage greater patient accountability and improve health through our highly trusted, accessible healthcare team. Source: www.walgreens.com
Sources (L to R): (1) Apple Insider. 2015. Walgreens Balance Rewards card gains Apple Pay compatibility. Retrieved from http://appleinsider.com/articles/15/11/05/walgreens-balance-rewards-card-gains-apple-pay-compatibility. (2) CVS. Retrieved from www.cvs.com. (3) National Community Pharmacists Association. Simplify My Meds Program. Retrieved from http://www.ncpanet.org/solutions/adherence-simplify-my-meds
INDEPENDENTLY OWNED PHARMACY SERVICES Refill synchronization 90-day supply of medications Medication therapy management services Medication reconciliations Home delivery services Brown Bag events Educational and outreach programs
Pharmaceutical Manufacturers Merck Engage: https://www.merckengage.com/medicine Pfizer: http://www.pfizer.com/health/senior_health/taking_medicines Eli Lilly: http://www.lillydiabetes.com/programs-resources.aspx
BEST PRACTICES
BEST PRACTICES Asheville Project Medication Therapy Management MIRIXA
BEST PRACTICES North Carolina Medicaid: Pharmacy Home Refill Synchronization Patient-Centered Medical Home
NATIONAL COUNCIL ON PATIENT INFORMATION AND EDUCATION (NCPIE) PRIORITIES FOR ACTION Increase Awareness: National Education Campaign Professional training Develop medication adherence curriculum for medical schools and allied health programs Source: NCPIE: Enhancing Prescription Medicine Adherence: A National Action Plan.
NATIONAL COUNCIL ON PATIENT INFORMATION AND EDUCATION (NCPIE) PRIORITIES FOR ACTION Multidisciplinary approach Federal funding for research Sharing best practices Common adherence terminology Source: NCPIE: Enhancing Prescription Medicine Adherence: A National Action Plan
EFFECTIVE STRATEGIES FOR IMPROVING MEDICATION ADHERENCE Team-based care Pharmacist-led multicomponent interventions Education with behavioral support Single dose vs. multiple dose prescribed Sources: Walsh J, McDonald K, Shojania K, et al. 2006. Quality Improvement Strategies for Hypertension Management: A Systematic Review. Medical Care. 44:646-57; Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. 2012. Interventions to Improve Adherence to Self-Administered Medications for Chronic Diseases in the United States: A systematic Review. Ann Intern Med. 157(11):785-795.
STRATEGIES FOR IMPROVING MEDICATION ADHERENCE New England Health Institute Medication Therapy Management Services Individualized drug Reduce drug cost barriers Address patient behaviors and preferences Continuity of care Physician support and engagement Targeting and stratifying at-risk populations Pay-for-performance or outcomes Health information technology Technologies for reminders and monitoring Source: NEHI. August 2009. Thinking Outside of the Pillbox.
PHYSICIAN LED-INTERVENTIONS S: Simplify the regimen I: Impart knowledge M: Modify patient s beliefs and human behavior P: Provide communication and trust L: Take time to overcome cultural and language barriers E: Evaluate adherence Source: Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21 st Century.
THANK YOU For more information about Quality Insights Hypertension and Diabetes Control & Management project, please contact Andrea Rodi at: E-mail: arodi@wvmi.org Phone: 877.725.9998, Ext. 127 Cell: 302.559.1925 This publication was supported by the Cooperative Agreement Number 1U58DP004799-01 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.