Medication Adherence

• The following module is designed as a basic overview of medication adherence for providers of healthcare, particularly those in a patient-centered medical home.

• At the end of this module, the reader should be able to:– Define “adherence”– Name 3 factors which affect adherence to medical advice– Outline 3 practical tips to improve adherence to

treatment regimens

Magnitude of the Problem

• “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”

Haynes RB. Interventions for helping patients to follow prescriptions for medications.Cochrane Database of Systematic Reviews, 2001, Issue 1.

World Health Organization has an action plan

Adherence

• Adherence -“the extent to which a patient acts in accordance with the prescribed interval and dose of a dosing regimen”

• 70% of ambulatory visits involve medications• Crosses all demographic and diagnostic groups

Magnitude of the Problem

• In developed countries, adherence to long-term therapies in the general population is around 50% and is much lower in developing countries.

• Noncommunicable diseases,mental health disorders,HIV/AIDS and tuberculosis, combined represented 54% of the burden of all illness worldwide in 2001 and will exceed 65% of the global burden of disease in 2020

WHO: Adherence to long-term therapies: evidence for action. 2003

Outcomes and Cost DataEffect of Adherence on Outcomes• Patients who stopped taking all of their cardiovascular medication one month after a heartattack were three to five times more likely to die compared with those who continued at leastone of their medications (Ho et al, 2006).• Patients with heart disease who reported taking their medications less than half the time hadalmost double the risk of cardiovascular events (Gehi et al, 2007).• Patients with diabetes and good medication adherence had 2.2% lower A1c level comparedto patients with poor adherence (Rhee et al, 2005).

Effect of Adherence on Costs• Although good adherence can lead to slightly higher medication costs in patients with

diabetes, high cholesterol or hypertension, total medical costs are about $1000 to $8,000 less due to avoided hospitalizations (Sokol et al, 2005).

• For patients with diabetes, every 10% increase in adherence is linked with a 4% decrease in total medical costs (Shenolikar et al, 2006).

WHO “Lessons Learned”1. Patients need to be supported, not blamed2. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs3. Improving adherence also enhances patient safety4. Adherence is an important modifier of health system effectiveness5. Improving adherence might be the best investment for tackling chronic conditions effectively6. Health systems must evolve to meet new challenges7. A multidisciplinary approach towards adherence is needed

WHO: Adherence to long-term therapies: evidence for action. 2003

The 5 Dimensions of Adherence

WHO: Adherence to long-term therapies: evidence for action. 2003

Some factors associated with adherence

• lower long-term medication safety concerns• greater trust in the prescribing care provider• higher perceived value of prescription medications• less perceived proneness to side effects• lower perceived value of supplements, minerals, and

vitamins• more knowledge about the prescribed medication• more perceived disease severity• better self-rated health• higher education attainment

WHO: Adherence to long-term therapies: evidence for action. 2003

Patient Barriers• Complexity: “There are so many pills, I can’t keep them straight!”• High cost: “I can’t afford my medicine so I will only take half a pill

today.”• Difficulty remembering schedules: “I forget to take them.”• Lack of understanding: “Why do I need them?”• Not feeling sick: “I feel fine. I don’t need them.”• Side effects: “The yellow pills make me feel sick and I heard the blue

pills give you liver problems.”• Embarrassment/Stigma: “I don’t want my friends to know that I’m sick.”• Depression: “I don’t care…. What’s the point?”• Health literacy: “I can’t understand these instructions!”• Belief systems: “My sister took insulin, then had her leg amputated.”

Practical Tips• Assume patients are not taking their medications correctly.• Ask: “What concerns you most about your medicine?”; “A lot of

people have trouble taking medicine the way their doctors ask them to. What gets in the way of taking your medicine?”

• Review medications with patients: indications, directions for use, side effects, cost-saving strategies – use the AVS

• Teach strategies for remembering medicine: pill boxes, cell phone reminders

• Explain in plain language: how the medicine works, consequences of not taking medicines, how to manage side effects

• Offer resources: PharmD, Patient assistance, MSW, $4 generics and free meds

References

• http://www.nyc.gov/html/doh/downloads/pdf/cardio/cardio-map-tools-manual.pdf

• http://apps.who.int/medicinedocs/en/d/Js4883e/

Questions

• I have read each slide in this module and understood its content– True– False