mpa adherence presentation handout_mcrowe

7/29/2019 MPA Adherence Presentation Handout_MCrowe

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I NEVER MISS A DOSE

MEDICATION ADHERENCE FOR THE

PRACTICE OF PHARMACY

Mike Crowe, PharmD

Clinical Pharmacist

My Pharmacist Now, PLLC

Diplomat Specialty Pharmacy

LEARNING OBJECTIVES

At the end of this activity, the participant will be able to:

1. Discuss various measures of medication adherence;2. List several positive and negative factors correlating with

medication adherence;

3. Identify negative outcomes of medication non-adherence; and

4. Describe available tools for predicting and improving apatients medication adherence.

AMERICAS OTHER DRUG PROBLEM1,2

Each year $290 billion is spent onavoidable medical costs due to

medication non-adherence.

Hospitalizations (33-69%)

Preventable adverse drug events (21%)

Deaths (125,000/year)

WHYTHE HYPE?

More available literature

Established benefits for all parties

Involvement of ke stakeholders

Enhanced public awareness

Becoming a market by itself

INCREASING LITERATURE

400%

500%

600%

700%

PubMed Search Term Percent Growth Since 1990

"Adherence"

0%

100%

200%

300%"Hypertension"

"HIV"

BENEFICIALTO ALL PARTIES3,4

Hypertension $3.98

Medical Costs Reduction forEach Dollar Spent Adhering

Patients

Pharmacies

$0.00

$5.00

$10.00

Diabetes

Hyperlipidemia

$7.00

$5.10anu ac urers

Physicians

Payers


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KEY STAKEHOLDERS INVOLVED5,6

National Council on

Patient Information and

Education issues nationalaction plan, including public

education campaign onmedication adherence

National Consumer League begins researchcampaign with funds from Agency for Healthcare

Research and Quality for public education effort

Centers for Medicare and Medicaid

Services add adherence to lan ratin s

World Health Organization

states increased adherence wouldhave greater impact than any

improvement in medical treatment

2003 2007 2012

Department of Health and Human

Services issues request for information

regarding medication adherence

INTHE NEWS

Non-adherence becoming apparent to:

Patients

Entrepreneurs

A MARKET BY ITSELF4

Lucrative opportunities for:

Wholesalers

o ware an app ca on eve opers

Consultants

QUESTION

JC is prescribed simvastatin 40 mg to be taken once daily. JCtakes the prescription to his pharmacy to have it filled andreceives a 30 days supply of the medication. Thirty days laterhe is out of this medication.

A. JC is adherent

B. JC is non-adherent

C. Cannot tell if JC is adherent

DEFINING MEDICATIONADHERENCE7

The extent to which patients take medications

as prescribed by their healthcare providers.

Often reported as percentage of prescribed doses actuallytaken by the patient over a specified period

Includes proper:

Timing

Dosage

Frequency

TERMINOLOGY DISPUTE7,8

Compliance Adherence

VS.


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ADHERENCE: A COMPLEX PROCESS8

1. Keep scheduled appointment with prescriber

2. Accept a prescription for medication(s)

3. Fill the prescription at a pharmacy

4. Take the medication as prescribed

5. Refill the prescription in a timely manner

6. Return to the provider for necessary monitoring

EPIDEMIOLOGY8

Most common type of non-adherence is error of omission

White coat adherence common

Near perfect adherenceNearly all doses taken with

Missed doses occasionally

with some timing irregularity

Drug holidays 3-4 times/year

with occasional omissions

Drug holidays monthly or

more with frequent omissionsFew or no do ses taken

INTENTIONS BEHIND NON-ADHERENCE9

Intentional

Skipping doses

Taking smaller doses

Altering the dose

70.1%

Previous Six Months

Stopping medication

Unintentional

Forgetting

Running out

Careless about takingUnintentional

Intentional

34.3%

ADHERENCE BARRIERS10

Forgetfulness,30%

Decision to omit,

Lack of

information, 9%

Emotionalresponses, 7%

No reason

provided, 27%

Other priorities,

16%

QUESTION

Direct measures of medication adherence include each of thefollowing except:

A. Observing a patient administer his/her doseB. Measuring the drug levels in a patients blood

C. Checking refill history

MEASURES OF ADHERENCE8,11

Direct methods

Patient self-reports

Pill counts

Assessment of clinical responseElectronic monitors

Physiologic markers

Prescription refill history


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DIRECT MEASURES OF ADHERENCE8,11

Measure Advantages Disadvantages

Direct observance Most accurate

Impractical Patient can hide dose

Ex ensive

Drug assay Objective Metabolic variations White coat adherence Snapshot only

Biologic markers Objective Expensive Snapshot only

SELF-REPORTED ADHERENCE8,11

Advantages

Simple and inexpensive Most useful method in clinical setting

Patient recall makes susceptible to error

Results can be distorted by patient

May create Hawthorne Effect

PILL COUNTS8,11

Advantages Objective

Quantifiable

Eas to erform

Disadvantages Easily altered by patient

No information on other aspects of adherence

Tedious process

ASSESSMENT OF CLINICAL RESPONSE8

Advantages Simple

Generally easy to perform

Factors other than adherence can affect

ELECTRONIC MONITORING DEVICES8,11

Advantages

Precise, more accurate than pill counts

Results easily quantifiable

Tracks adherence atterns

Disadvantages

Expensive

May take wrong amount

Dont always equate to ingestion

Some require downloading of data

PHYSIOLOGIC MARKERS8,11

Advantages Often easy to perform

Disadvantagesar er may e a sen or reasons

other than non-adherence


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PRESCRIPTION REFILL HISTORY8,11

Advantages

Objective Easy to obtain and relatively inexpensive

Avoids Hawthorne Effect

Disadvantages Refill does equate to ingestion or correct dose timing

Requires closed pharmacy system

Does not account for acute treatments

Inaccurate days supply will distort rates

May be overstated early on in therapy due to dose adjustments

MEDICATION POSSESSION RATIO (MPR)12

Most commonly used method for claims-based adherence

May overestimate adherenceReporting measures vary by source

( )

umma on o ays supp y v e y se per o o me

MPR =Sum of days supply for all fills in period

Number of days in periodx 100%

PROPORTION OF DAYS COVERED (PDC)12

More conservative estimate of adherence

Better suited for medication regimens vs. MPR

Endorsed by Pharmacy Quality Alliance (PQA)

Adopted by CMS for plan ratings

( )

Not a simple summation of days supply

PDC =Number of days in period covered

Number of days in periodx 100%

MPRVS. PDC12

Drug 3

Drug 2

Drug 1

Prescription Fill History and Days Supply

30 Days Supply 30 Days Supply 30 Days Supply 30 Days S

30 Days Supply 30 Days Supply 30 Days Supply

30 Days Supply30 Days Supply 30 Days Supply 30 Days Supply

0 10 20 30 40 50 60 70 80 90 100

Drug 4 30 Days Supply30 Days Supply 30 Days Supply30 Days Su

Statistic Drug 1 Drug 2 Drug 3 Drug 4 Regimen

Days Supply (S) 100 90 110 100 n/a

MPR ( S / 100 ) 1.00 0.90 1.10 1.00 1.00

Days Covered (C) 100 90 100 90 n/a

PDC ( C / 100 ) 1.00 0.90 1.00 0.90 0.80

QUESTION

What is the PDC for this patients HIV treatment regimen?

A. 100%

B. 40%

0 10 20 30 40 50 60 70 80 90 100

Drug 3

Drug 2

Drug 1

Prescription Fill History and Days Supply

30 Days Supply 30 Days Supply30 Days Supply

30 Days Supply 30 Days Supply 30 Days Supply

30 D

30 Days Supply 30 Days Supply 30 D

.

PERSISTENCY: PART OFADHERENCE7,11

ADHERENCE

% of doses taken as prescribed

PERSISTENCE

days taking medication w/o exceeding gap

Start Medication or

Observation

Stop Medication or

End Observation

X X X


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WHAT IS OPTIMAL?8

No consensus on optimal adherence level

80% acceptable for many disease states 95% for more serious conditions

One of two oals:

Dichotomous (yes/no to predefined level)

Continuous (0-100%)

CORRELATES TOADHERENCE8,13

Not consistently associated with adherence:

Race Sex

Socioeconomic status

Based around three Cs Commitment

Concern

Cost

COMMITMENT AND COST (+)9

Ranked Quartile

Perceptions

Non-Adherence Rate

Perceived

Need

Perceived

Affordability

1 Absent 75.5% 82.2%

2 (Low) 74.7% 72.9%

3 (Moderate) 70.7% 68.3%

4 (High) 62.0% 59.6%

REMOVAL OF COST BARRIERS (+)14

3.0%

4.0%

5.0%

Effects of a Value-Based Insurance Design

0.0%

1.0%

2.0% Over 1 Year

Over 2 Years

NEGATIVE ADHERENCE CORRELATES2

National Council of Patient Information and Education

1. Poor patient/provider communication

2. Unresolved patient concerns

3. Provider issues4. Special patient population issues

5. Regimen related barriers

6. Environmental barriers

POOR PATIENT-PROVIDER

RELATIONSHIP (-)8,15,16

Non-adherence commonly caused by misunderstandings

Providers less satisfied with job have less adherent patients

Most important components of relationship

Trust Communication

Caring

Patients must be able to

Ask questions

Voice concerns

Collaborate on plan


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PERCEIVED CONCERNS (-)9

Examples

Perceptions about the seriousness of the illnessDisagreement with the diagnosis or treatment

Ranked Quartile

Perceived ConcernsNon-Adherence Rate

1 (Absent) 61.3%

2 (Low) 70.7%

3 (Moderate) 73.6%

4 (High) 77.6%

COMPLEXITY OFTREATMENT (-)17

Regimen

Frequency

Mean

Compliance (%)

Standard

Deviation (%)Range (%)

1 dose/d (QD) 79 14 35-97

2 doses/d (BID) 69 15 38-90

3 doses/d (TID) 65 16 40-91

4 doses/d (QID) 51 20 33-81

QD versus TID, p = 0.008

QD versus QID, p < 0.001

BID versus QID, p = 0.001

QUESTION

Medication non-adherence can lead to which of the followingnegative outcomes?

A. Reduced quality of life for the patient

B. Strained patient-provider relationship

C. Both A and B

NON-ADHERENCE NEGATIVE OUTCOMES16

Patient and physician frustration

Misdiagnosis

Unnecessary treatment

Exacerbation of disease

Failure to receive quality awards for performance

HIV/AIDS5,8,18

Challenges

Side effects or fear of side effects

Co-morbidities

Fewer healthcare options

Unforgiving medications

High pill burden

Stigma

Resistance and treatment failure

Opportunistic infections

Specific improvement considerations

Establish family and friends support system

Patient education on relation between adherence and viral load

Simplifying regimen (remove food and storage restrictions)

Regularly assess and manage side effects

CARDIOVASCULAR DISEASE4,8,19

Challenges

Often asymptomatic

Multiple medications required

Poor outcomes Hospitalization

Death

Improvement considerations

Self-monitoring of blood pressure

More forgiving antihypertensives

Combination antihypertensives


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PEDIATRIC PATIENTS8,20,21

Challenges

Childs cooperation

Reliance on guardian

Lifestyle issues

Uncontrolled/uncured disease

Antibiotic resistance

Specific improvement considerations

Token reinforcement system

Use more palatable medications

Involve family members, schools, and other social supports

Provide written support materials

Pill swallowing training

Challenges

Side effects

Dosing requirements

Poor outcomes

Silent disease

Misconceptions about treatment

OSTEOPOROSIS15,22,23

-

Adherence reduced risk of hospitalization due to fracture by 20-30%

Specific improvement considerations Allowing patient to decide frequency of dose

Interventions to correct misconceptions

Providing individual treatment plan

Show patients evidence of need for treatment and positive results

DIABETES18,24,25

Challenges

Multiple comorbidities/medications (statin, antihypertensives)

Poor outcomes

Adherence < 80% linked to increased blood pressure , A1C, LDL

, , -

Adherent patients have $4,000 less annual medical costs

Specific improvement recommendations

Involve patient and family in education and treatment goals

Establish collaborative patient-provider relationship

Simplify medication regimen

GERIATRIC POPULATION1,26

Non-adherence related to 21.1% of avoidable ADEs

Geriatric patients base prescription importance on

Drug-related factors

Patient-related factors

External factors

Higher importance associated with higher worth

ADHERENCE PREDICTION TOOLS13

Over 25 adherence screening tools

Goal is to create efficiency through targeted interventions

Predictive evidence is lacking

MORISKY SCALE27

First developed and tested in 1986

Studied in many disease states

Question Answer

Do you ever forget to take your medicine? Yes/No

Are you careless at times about taking your medicine? Yes/No

When you feel better do you sometimes stop taking your medicine? Yes/No

Sometimes if you feel worse when you take the medicine, do you stop? Yes/No

Score 1 for each Yes; 0 = high; 1-2 = intermediate; 3-4 = low adherence


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ADHERENCE ESTIMATOR13

Developed by Merck in 2009

Assesses three Cs Commitment

Concern

Measure Low Risk Medium Risk High Risk

PDC (median) 0.655 0.598 0.484

MPR (median) 0.912 0.909 0.866

IMPROVEMENTTOOLS

Memory aids and devices

Applications and software for patientsRefill synchronizing programs

Forgiving medications

TECHNOLOGY25,28,29

Allows for patient-centered applications with

Medication reminders

Refill request function

Drug information access

ex message remn er su scr ers

Overall PDC improvement of 8% vs. nonusers

Online prescription management account enrollees

Overall PDC improvement of 18.74% vs. nonusers

REFILL SYNCHRONIZATION PROGRAM30

Simplify My Meds

National Community Pharmacists Association

Allows pharmacies to synchronize patient refills

Functions with iPad application, reminds staff

Check need for prior authorization

Check inventory

Check refills

Prepare refills

MOTIVATIONAL INTERVIEWING31

A directive, patient-centered counseling style for

eliciting behavior change by helping patients to

explore and resolve ambivalance.

A way of breaking down barriers

An approach shaped by understanding what triggers change

Not just a set of techniques

Validated in clinical trials to improve adherence

MEMORY AIDS/DEVICES4

Alarm devices

Automatic delivery to home

Pill boxes and multi-dose envelopes

CalendarsStrategic placement of medication

Patient diaries

Refill reminders (letters and calls)

Tokens or rewards


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FORGIVING MEDICATIONS32

For patients still struggling with adherence

Consider drug, disease, and formulation

Medications post-dose duration of beneficial action (D)

Prescribed dosing interval (I)

Forgiveness (F)

NO SINGLE APPROACH FORALL8

Provide education for patients and family members

Improve dosage schedules with pill boxes, simplifying theregimen, providing cues to remind patients of doses

Increase availability of appointments, make follow-upappon men s convenen an e cen

Improve communication between healthcare providers andpatients, including pharmacists

CONCLUSION

Medication adherence is a serious and costly problem

Non-adherence leads to many negative outcomes

Understanding how to measure adherence can help

eat care provi ers assess w en non-a erence is an issue

Using predictors of non-adherence and tools for improving

adherence, pharmacists can positively impact patient

outcomes

REFERENCES

Please refer to handout.

QUESTIONS

Please feel free to contact me with any questions.

Mike Crowe, PharmD

mcrowe m harmacistnow.com810.399.7589

POST-TEST QUESTION 1

True or False. Medication possession ratio (MPR) is morelikely to overestimate adherence than the proportion of dayscovered (PDC).

A. rue

B. False


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Which of the following has NOT been shown to correlatewith poor medication adherence?

A. Perceived concerns

B. Sex of the patient

C. Complexity of the regimen

D. Poor patient-provided communication


Which of the following is the least appropriately matchedspecial population with outcome of non-adherence?

A. Osteoporosis: increased fracture risk

B. HIV/AIDS: opportunistic infection

C. Diabetes: increased medical costs

D. Heart failure: amputation


Technologically-based interventions that have shown toimprove medication adherence include:

A. Text-messaging services

B. Online prescription management accounts

C. Electronic reminder devices

D. All of the above


Research has shown that medication non-adherence can befully corrected in all patients through which of the followinginterventions?

A. o-pay ass stance car s

B. Reducing medication dosing frequency

C. Synchronizing all medication refills

D. None of the above


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INeverMissaDose:MedicationAdherenceforthePracticeofPharmacy

References MikeCrowe,PharmD

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mpa adherence presentation handout_mcrowe

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