MEDICATION NONADHERENCE THE HIDDEN EPIDEMIC Drugs don t work in patients who don t take them. C. Everett Coop, MD 13 th Surgeon General of the United States February 3, 2018 Community Care of Wake and Johnston Counties and CCPN Network Providers meeting
OBJECTIVES Define medication adherence Review current adherence statistics Examine factors influencing medication adherence Illustrate tools for measuring and assessing medication adherence Identify solutions for improving medication nonadherence
DIFFERENTIATING ADHERENCE, COMPLIANCE AND PERSISTENCE Adherence: the extent to which a person s behavior [in] taking medication corresponds with agreed recommendations from a health care provider Compliance: suggests the patient is passively following the doctors orders, rather that actively participating in their treatment plan Persistence: Duration of time patient takes medication, from initiation to discontinuation of therapy (World Health Organization, 2003).
NONADHERENCE CAN INCLUDE Failure to fill new or refillable Rxs Omitting a dose or doses Overusing medication Prematurely discontinuing med Taking a dose at the wrong time Taking others meds Taking a dose with prohibited foods, liquids, or other meds Taking outdated meds Taking damaged meds Improper storage of meds Improper use of delivery devices (e.g., inhalers)
NONADHERENCE HOW BAD IS IT, REALLY?
EXTENT OF NONADHERENCE At any given time~50% of patients are nonadherent 30-50% NOT filled 34-52% NOT picked up 70-75% NOT taken properly 80-85% NOT refilled
THE BURDEN OF NONADHERENCE ANNUALLY > 10% of all hospital admissions 25% of hospital admissions among the elderly 23% of nursing home admissions ~ $300 billion in direct healthcare costs 125,000 deaths
THE FIVE DIMENSIONS OF ADHERENCE
SOCIAL AND ECONOMIC FACTORS Lack of English proficiency Low health literacy Lack of family or social support Unstable living conditions; homelessness Limited access to health care
SOCIAL AND ECONOMIC FACTORS Lack of health care insurance Inability or difficulty accessing pharmacy Medication cost Cultural and lay beliefs about illness and treatment
HEALTHCARE SYSTEM FACTORS Provider-patient relationship Provider communication skills Disparity between beliefs of provider and patient Lack of positive reinforcement from provider Diminished capacity for patient education & follow-up
HEALTHCARE SYSTEM FACTORS Poor knowledge of adherence and ways to improve Patient education materials above reading level Restricted formularies High drug costs, copayments Poor access to appointments Long wait times Lack of continuity of care
CONDITION-RELATED FACTORS Chronic conditions Lack of symptoms Depression Psychotic disorders Developmental delays
THERAPY-RELATED FACTORS Complexity of medication regimen (#daily doses; #of medications) Treatment requires mastery of certain techniques (injections, inhalers) Duration of therapy Frequent changes in medication regimen Lack of immediate benefit of therapy Medications with social stigma attached to use Actual or perceived unpleasant side effects Treatment interferes with lifestyle or requires behavioral changes
Visual impairment PATIENT-RELATED FACTORS PHYSICAL Hearing impairment Cognitive impairment Impaired mobility or dexterity Swallowing problems
PATIENT-RELATED FACTORS PSYCHOLOGICAL Knowledge about disease Understanding reason medication is needed Motivation Confidence in ability to follow treatment regimen Alcohol or substance abuse Perceived risk/susceptibility to disease
PATIENT-RELATED FACTORS PSYCHOLOGICAL Fear of possible adverse effects Fear of dependence Feeling stigmatized by the disease Frustration with health care providers Psychosocial stress, anxiety, anger
HOW DO WE MEASURE ADHERENCE?
MEASURING ADHERENCE Medication monitoring systems (MEMS) Pill counts Pharmacy databases Rapid Estimate of Adult Literacy in Medicine- Revised REALM-R Medication Knowledge Assessment Tool Morisky s Medication Adherence Scale (MMAS)
PHARMACY DATABASES Proportion of Days Covered (PDC): Examines each day in period to determine if the patient has the drug on hand While this method doesn t account for whether or not the patient actually took the medication it does provide information regarding whether the patient had possession of enough medication TO BE ADHERENT during a given time frame.
POSSESSION RATIOS THE GOOD PDC >= 80% AI >= 0.8 THE BAD PDC > 40% to < 80% AI > 0.4 to 0.8 THE UGLY PDC < 40% AI <0.4
MC 16YO FEMALE
MC 16YO FEMALE 17 7 Proportion of Days Covered 63%
RJ 17YO MALE -
RJ 17YO MALE - 7 7 3 Proportion of Days Covered 61%
HOW DO WE ASSESS ADHERENCE?
RAPID ESTIMATE OF ADULT LITERACY IN MEDICINE- REVISED REALM-R The REALM-R is an 11-word recognition test to identify people at risk for poor literacy Fat Allergic Fatigue Constipation Flu Jaundice Directed Osteoporosis Pill Anemia Colitis Those scoring < 6 are considered at risk for poor health literacy (Bass et al, 2003).
MODIFIED MORISKY SCALE
MODIFIED MORISKY SCALE
MOTIVATIONAL INTERVIEWING Patient-centered, approach to enhancing ones motivation to change by exploring and resolving their own ambivalence/ resistance Establishes confidence and trust Allows patients to disclose apprehensions or difficulties with regards to taking meds Allows pharmacists to tailor interventions aimed at improving adherence and health outcomes ASKING THE RIGHT QUESTIONS IS KEY!
SMURF System Motivation Understanding Recall Financial
PATIENT QUESTION TO ASSESS SYSTEM BARRIERS How difficult is it to travel to your doctor s office or pharmacy for appointments or refills? Do you have someone that helps you with your medications? Do you make one or multiple trips per month to the pharmacy for your medications?
SOLUTIONS TO SYSTEM BARRIERS Synchronize prescription fill dates Delivery or mail-out services Community shuttle Recruit the help of family members or friends
PATIENT QUESTIONS TO ASSESS MOTIVATION BARRIERS What are you taking this medication for? Do you feel your medication is harming you? How important do you feel this medication is for you? How important do you feel it is to treat [condition]? What bothersome effects do you feel are related to your medication? Does a particular effect make you hesitant to take your medication consistently?
SOLUTIONS TO MOTIVATIONAL BARRIERS Discuss patient s health condition and risk of under treatment Discuss expected benefits from adherence to therapy Develop a self-monitoring strategy Recommend administration techniques, OTC products, or non-drug strategies to manage adverse effects Involve caregivers and family members as needed
PATIENT QUESTIONS TO ASSESS KNOWLEDGE BARRIERS Can you explain to me how to take/use your medication/device? What did your doctor tell you about how to take your medication? How difficult is it to read and understand your medication labels and instructions? How do you like to receive printed information about your medicine; as information leaflets, handouts, diagrams pictures or another language? How satisfied are you with how well you medication works?
SOLUTIONS TO KNOWLEDGE BARRIERS Explain and have patient teach-back how to take/use medications/difficult devices Repeat and paraphrase instructions Utilize graphics/visual aids, provide translations of informational leaflets, or use a larger font size
PATIENT QUESTIONS TO ASSESS RECALL BARRIERS How often do you forget to take your medication? Are there medications you forget to take more than others? Is it more difficult to remember to take medications at a certain time of the day, such as before lunch or in the evening? What do you use to help you remember to take your medications? Could you describe your daily medication routine? How often do you feel overwhelmed because of the number of medications you take?
SOLUTION TO RECALL BARRIERS Consolidate medications into combination dosage forms Discontinue unnecessary medications Use bottle size, colored dots, or pictures to differentiate administration needs Initiate adherence packaging (unit dose /blister cards or packs) Enroll in automated refill reminder programs (emails, text messaging, telephone call Educate on Mobile Adherence APPs for Android and Apple
PATIENT QUESTION TO ASSESS FINANCIAL BARRIERS How difficult is it for you to pay for your medication? How often do you skip doses of your medication because of how much it costs?
SOLUTIONS TO FINANCIAL BARRIERS Therapeutic interchange Tablet splitting Combination product Manufacturers coupons, savings/discount cards Medication assistance programs NC MedAssist, needymeds.org
SCREENING TOOLS Making The Most of My Medications
SCREENING TOOLS 1. I see some of your medications could have been filled around. a. Do you still have some left at home? b. Have you received samples of this medication or had it filled at another pharmacy? c. How are you taking this medication? What time of day do you take this medication? d. How is taking this medication fitting into your schedule? 2. Remembering to take medications can be difficult for a lot of people. Thinking about the past week/month, how many times would you say you missed a dose of your medications? Assess and Address in 5 minutes or Less a. What times of day are you most likely to miss a dose? b. What have you tried in the past to help you remember to take your medications? What works well for you? c. What are your biggest challenges with taking your medications? 3. How do you feel your medications are working for you?
SCREENING TOOLS SOLVE & INVOLVE 1. Summarize specific target behavior/goal: a. So, just to be sure I understand, it sounds like controlling your condition) is important to you, for/because (reasons). Due to (barriers), it s been hard taking your medications every day as prescribed. 2. Help the patient make a S.M.A.R.T. plan (Specific, Measurable, Achievable, Relevant and Timed) a. What is something you d like to do to help you remember to take your medications in the wk(s)/mo? b. That sounds like an important goal. Many people find it useful to have a specific plan. c. When do you see yourself doing this? (How do you see this fitting into your schedule?) d. When would be a realistic start date? e. Who might you see helping and supporting you with this? 3. Elicit a commitment statement: a. Just to make sure we both understand your plan, would you mind sharing it in your own words? b. How confident are you about completing your plan? 4. Identify potential barriers to the plan and establish follow : a. What things do you think could get in the way of your plan? b. What could you do to prepare for these problems?
STRATEGY RECAP ASSESS & ADDRESS Use initial screen Making the most of my Medications question to identify barriers (SMURF) Review refill request history to assess non-adherence and consider Assess and Address questions for any additional concerns not identified from initial screen MOTIVATE & NEGOCIATE Highlight positive behavior, have open discussions and emphasize patients choice in making health care decisions Listen and validate patient concerns, Reinforce safe & effective use of medications SOLVE & INVOLVE Collaboratively to develop a med adherence plan with the patient, set achievable goals Schedule follow-up Stay involved; engender continuous partnership ; congratulate on successes
REFERENCES 1. New England Healthcare Institute: Thinking Outside the Pillbox: A system-wide approach to Improving Medication Adherence for Chronic Disease; August 2009. 2. Henry J Kaiser Foundation, May 2010 3. Medication Non-Adherence: The Hidden epidemic Managing Medication Adherence & A Safe Hospital Discharge; [PPT].David R. Donahue, M.A.,Qualitative Technoligies, Inc. Milwaukeem WI, Dr. Tom Muscarello,PhD, DePaul University, Chicago, IL. 4 World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Publication WHO/MNC/03.01. Geneva, Switzerland: WHO; 2003. 5. Medication Adherence: Its importance in Cardiovascular Outcomes; P. Michael Ho, MD, PhD; Chris L. Bryson, MD, MS; John S. Rumsfeld, MD, PhD. Circulation. 2009; 119:3028-3035. 6 American Heart Association http://www.americanheart.org. National Council on Patient Information and Education. Enhancing Prescription Medicine Adherence: A National Action Plan 2007. 7.Vermeire, E., et al. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001 Oct;26(5):331-42.and American Heart Association 8. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43(6):521-530. As cited in: Pharmaceutical Research and Manufacturers of America (PhRMA). Value of Medicines: Facts and Figures 2006. August 10, 2006. p. 37.