Americas Vexing Drug Problem

Medication Adherence:To Take or Not To Take?

Although more diseases than ever can be controlled, few can be cured.And although modern medicine can sometimes work wonders, pharmacologic treatments do not work if patients dont take themThe fact that patients are not taking their medications and its impact on patient outcomes is truly underappreciatedWe are facing an EPIDEMIC of patient nonadherence This program reviews some of the current thinking on this topic with particular emphases on how pharmacists may incorporate this knowledge into their practice 1Adherence vs. Compliance Adherence: the degree to which a persons behavior coincides with medical adviceAdherence requires the patients agreement with the recommendationsCompliance may suggest a passive approach by the patient to health care

What we are referring to poor adherence / compliance These 2 terms are not synonymousAdherenceWHO: adherence is the degree to which a persons behavior corresponds with the agreed recommendations from a health care provider This term assumes collaboration between patient and health care provider regarding the pts health ComplianceCompliance suggests a passive approach to health care on the part of the ptThis paternalistic view does not encourage the pt to take an active role in his health care

Although adherence is generally recognized in the medical community, compliance has been used much more frequently 2PersistenceOverall duration of drug therapyThe interval between date of first Rx and point where patient would have insufficient supply of drug to cover days between Rx refills

NEEDED: Hybrid TermDefines patients medication-taking behavior in terms of both duration & intensity Another term used to describe medication taking behavior

PersistenceOverall duration of drug therapy - - the treatment continium Basically the interval between the date of the first Rx fill & the last HybridQuantifies the total duration of therapy Quantifies the intensity of medication taking within this interval

There is no standardized method for objectively evaluating either issue

3What is the most common type of dosing error?Dose omissionExtra dose takenMisscheduled doseIncorrect dosage

Poor adherence can take many forms from taking the wrong dose to stopping the regimen early.

What is the most common type of doing error made by patients? Correct answer is #1Most variations from a prescription occur as a dose lapse rather than as an extra dose or misscheduled dose4How Much is Enough?Adequate AdherenceDrug & disease dependentMost researchers use 80%

You may ask How much is enough???There are no agreed upon standards for what constitutes adequate adherenceTherapeutic sufficiency depends on the drug being used & the disease being treatedFor example, some experts think adherence rates of > than 95% adherence are necessary in the treatment of patients with serious conditions such as HIVWhile, the treatment of other diseases such as HBP or hyperlipidemia might not require such strict adherence for an acceptable therapeutic benefit An adherence rate of at least 80% is a commonly accepted cut point for defining an acceptable level of med adherence

5Lets Look at the Numbers14% of all written prescriptions are never filled13% are filled but never takenChronic diseases: Adherence drops most dramatically after first 6 months 50% drop out of treatmentOf those who continue, typical rates of adherence are 50 to 60%

Lets look at the numbersIn general:14% of all written prescriptions are never filled13% are filled but never taken

Chronic administration:Adherence drop dramatically after first 6 months of therapyPatients typically take less than half the prescribed doses

The rates of nonadherence have not changed much over the past 3 decades

6Patients with which of the following diseases or conditions are most likely to adhere to their medications?Diabetes HIVSeizure disordersOrgan transplant

Nearly identical patterns of adherence have been demonstrated in patients with a variety of diseases (hypertension, seizure disorders, glaucoma, or other clinical scenarios such as hormone therapy & lipid reducing agents)

In addition, the degree of adherence and pattern of med-taking is similar regardless of the severity of the disease being treated

7What are the Consequences?Causes 125,000 deaths annually10% of hospital and 23% of nursing home admissions are linked to nonadherenceNonadherence directly costs the US health care system $100 billion annuallyAnnual indirect costs exceed $1.5 billion in lost patient earnings and $50 billion in lost productivity

Consequences of poor adherence can range from minor to serious depending on the drug characteristics, the disease and its severityExamples of consequences include: increased ER visits and hospitalizations for asthma, increased mortality with poor compliance to cholesterol-lowering drugs and breakthrough seizures in epilepsy

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In one study, even accounting for savings in drug costs, patients who took less than 20% of the lipid-lowering meds had more than $3000 greater yearly health care costs than do patients with at least 80% adherence (Am J Manag Care 2006;12-28 abstract)8Adherence Post MI HospitalizationEvaluated 1521 patients use of ASA, beta blockers & statins one month post hospitalizationPatients who discontinued use of all medications had lower 1 year survival (88.5% vs 97.7%) compared with those taking 1 or more of the medication

Studied 1521 patients and assessed their use of ASA, beta blockers and statins ONE MONTH after hospitalization for MIabout 1 in 8 discontinued all 3 meds after one month1 in 5 stopped using 1 med1009 continued taking all 3 Those who stopped taking their meds had a significant increased mortality during the subsequent 11 months compared with those who continued to take any one med, even after adjustment for demographics, clinical hx, psychosocial factors & MI treatment variables

Current quality improvement efforts for MI care are mainly focused on the inpatient setting. The findings of this study suggest that an important quality gap in current MI care may not occur during the hospitalization.

9Adherence Rates & BP ControlRetrospective evaluation of >10,000 pt with coronary disease, followed a mean of 4.6 yearsInvestigated causes of treatment failures1/3 of cases: failure to intensify treatment1/3 of cases: medication nonadherence67% did not fill Rx despite therapy intensification Conclusion: Importance of communication between clinician & pt

Arch Intern Med.2008;168(3):271-76This study investigated the reasons why people fail to have their BP controlled1/3 of cases: clinicians failed to intensify pts antihypertensive regimens even though the pts had persistently high BP levels1/3 of cases, pt were nonadherent ( defined as filling Rx for 3 antiretroviral meds living in single-room hotels & homeless sheltersDesign: Pillbox organizers 12 month trial with unannounced pill counts conducted every 3-6 weeks @ patients residence Monthly assessment of HIV load Results: Pillboxes improved adherence by 4.1 to 4.5 %Improved viral suppression14-16% higher probability of achieving a viral load < 400 copies/mL

Clin Infec Dis 2007;45:908-15 Pt PopObservational cohort of 245 pt who were followed for 1 year in San FranPt recruited from single room occupancy hotels, homeless shelters & free meal programsAll were taking 3 or more antiretroviral agentsIntervention / DesignPillboxesUnannounced pill counts every 3-6 weeks @ pts residenceBlood samples collected & assessed monthly for HIV loadResultsPillboxes were associated with a 4 to 5% higher adherence and improved viral suppressionAuthors conclude that given the simplicity & low cost of the intervention, clinicians should consider including pillbox organizers in their routine tx of chronic disease

54This I KnowThere is no single intervention strategy that is effective for all patientsMost interventions have a positive effect in the short term, but to be successful in the long term, a sustained multifactoral approach is required Interventions must be tailored to the needs of the individual patient The gains in adherence achieved are typically < 20%For decades we have searched for that one perfect solution to the adherence problem, however, there does not seem to be any one intervention that robustly enhances adherence 55To reap the benefits of modern medical therapies, better, more effective, and more efficient interventions for helping people follow regimens are needed.

Although the challenge of poor med adherence has been discussed & debated at least 3 decades, these problems have generally been overlooked as a serious public health issue. As a result it has received little direct, systematic or sustained intervention

Pharmacists can play an important role in helping to achieve this goal 56