How to Improve Medication Adherence in 8 Steps

“Drugs don't work in patients who don't take them.”
- C. Everett Koop, M.D.
 Surgeon General of the United States, 1982-1989
 
When Dr. Koop made this seemingly simple statement 20 years ago, he could not have predicted the billions of dollars that are now wasted every year by patients’ non-adherence to their medication regimen.
 
Adherence is defined as the extent patients take their medications as prescribed, such as twice daily, and suggests an effort by the patient. Compliance is considered a synonym for adherence but suggests a more passive patient role, e.g. a lack of involvement from the patient and coercion by the provider. Another term often used when discussing adherence is persistence; defined as the length of time the therapy has been prescribed, e.g. 30 days. To receive optimal benefit from a medication regimen, a patient must adhere (comply) and persist. The measurement of adherence is typically reported as the medication possession ratio (MPR).

To support patients’ medication adherence, it is critical to understand the scope of barriers patients face. Healthcare providers can only help to solve this national epidemic if they are aware of patients’ challenges to adherence. 

Barriers
Researchers identified over 200 factors (see Table I below) that led to the lack of medication adherence in patients participating in clinical trials. However, the three most common factors are:

1. Forgetfulness
2. Understanding
3. Medication Cost

Forgetfulness
In 2009, Kelton Research conducted a poll with results providing a profile of individuals in the U.S. who are 65 years old and older and who use medications:

• 51% take at least five different prescription drugs regularly
• 25% take between 10 and 19 pills each day

Non-adherence is not limited to the elderly. Research results published in the Alimentary Pharmacology & Therapeutics demonstrated that 61% of patients younger than 40 years old with inflammatory bowel disease, primarily ulcerative colitis and Crohn’s disease, self-reported as non-adherent due to having to take medication, often multiple doses, while at work.
 
Understanding
To truly ensure adherence, patients must fully comprehend their condition, the short and long-term effects of their condition, how their prescribed medication will resolve their condition, how to take their medication, their medication’s potential side effects, how to prevent or address side effects, how regularly they need to visit their providers, and how often they should have blood tests to measure their circulating medication level, if appropriate.
 
Cost
In 2010, there were approximately 29 million documented residents in the U.S. who were considered underinsured. Sadly, individuals with enviable insurance plans find themselves unable to afford their co-pays when they must take specialty medications to treat life-threatening or chronic conditions.
 
The creation of Medicare Part D for individuals age 65 and older in 2006 dramatically improved patient access to prescription medications. However, patients are exposed to the “doughnut hole,” a gap that results in large out-of-pocket expense for their medications once they’ve exhausted their initial coverage.

Irrespective of insurance status, financial exposure, especially for newer, specialty drugs, such as oral oncology drugs, can cost $8,000-$15,000 per month, resulting in extreme out-of-pocket costs, decreased adherence or leaving prescriptions unfilled. 

Solutions
The causes and factors that contribute to medication non-adherence are multi-faceted. Patients with overlapping categories have the highest probability of adherence. For example, a patient without family or a support network is more likely to be non-adherent. However, there are strategies and tools available that foster adherence.

1. It is incumbent upon providers and their office staff to educate patients throughout their therapy. Education should not begin and end with the first new prescription.
 
2. The relationship of health outcomes as a result of positive and negative adherence rates must be clearly outlined to patients.
 
3. Patients must be aware of the risks for adverse events and the tools to minimize them, as well as when the situation is sufficiently urgent to contact their healthcare provider.
 
4. Never assume a patient understands. Use open-ended questions to confirm patients’ comprehension and to engage and empower them to participate in their care.
 
5. Encourage patients to develop a health goal to improve behaviors and outcomes.
 
6. Create a multi-disciplinary healthcare team, comprised of the patients’ provider, nurse, and dispensing pharmacy, with each member accountable for patient outcomes. Communication should be freely exchanged on the treatment goals and barriers to successful outcomes.
 
7. Regularly conduct patient outreach using multiple vehicles, such as live scheduled calls, automated calls, letters, email, text-messaging, etc.
 
8. Identify the pharmacy that can support patients, particularly those on specialty medications.
 
Specialty medications are high-cost injectable, infused, oral, or inhaled drugs that generally require special storage or handling and close monitoring of the patient's drug therapy. It is prudent to direct patients on these medications to specialty pharmacies to maximize patient outcomes.
 
Avella, for example, offers every patient the following services:

• A financial assistance team that has extensive training in assisting underinsured patients to minimize their financial risk. Avella team members have strong working relationships with several non-profit organizations and manufacturers that offer financial assistance. (Cost)

• Each patient has a dedicated pharmacy contact who is a subject matter expert in the patients’ condition. This specialty care coordinator reaches out to patients every month to personally inquire about their health, to conduct a screening to assess patients’ understanding of their conditions, to evaluate compliance, and to see if a medication refill is in order. (Forgetfulness and Understanding)

• A clinical pharmacist contacts patients with new prescriptions to counsel them about their specialty medication. (Understanding)

• Free monthly medication shipments. (Cost)

• Avella is able to offer patients on certain medications an innovative electronic medication reminder, GlowCap®.  The GlowCap is placed on the prescription bottle and a wireless reminder light plugs into a kitchen or bathroom outlet and pulses and glows orange at a predetermined time. It is a subtle reminder for a patient to take one’s medication.(Forgetfulness)

• In addition to the services noted, Avella clinical pharmacists have developed written educational tools that are shipped with patients’ medication. These easily read one to two-page fliers reinforce the topics covered during patient counseling calls. (Education and Understanding)

Summary
Poor adherence to medication is common and it does not discriminate based on the severity of disease, age, race, or socioeconomic status. Suboptimal adherence rates to medications contribute to poor outcomes, worsening of disease, death, and increased healthcare costs. Numerous reasons contribute to a patient’s poor adherence rate with forgetfulness, lack of knowledge, and costs being the most common. Engaging patients with open-ended questions to determine where potential barriers lie and using a multi-disciplinary approach with a specialty pharmacy to present innovative techniques to educate, empower, engage, and remind patients on the importance of adherence is critical in managing chronic disease states.

Learn more today by reading the full article in our publication; Dispensing Excellence