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Sticking With What Works: Helping Patients Adhere to

Medications

Daniel R. Touchette, PharmD, MA

Jessica Tilton, PharmD, BCACP University of Illinois at Chicago

College of Pharmacy

March 12, 2012

2 2

Supported by independent

educational grants from

Abbott Laboratories and Merck.

3 3

The American Pharmacists Association is accredited by the

Accreditation Council for Pharmacy Education as a provider of

continuing pharmacy education.

This activity, Sticking With What Works: Helping Patients Adhere to

Medications, is approved for 2.0 hours of CPE credit (0.2 CEUs). The ACPE

Universal Activity Number assigned by the accredited provider is 202-000-12-082-

H04-P for pharmacists and 202-000-12-082-H04-T for technicians. If you

participated in the live seminar of the same title held on Monday March 12, 2012 at

the APhA Annual Meeting and Exposition in New Orleans, LA you are NOT eligible

to receive CPE credit for this activity.

To obtain CPE credit for this activity, participants must view the slides and listen to

the audio for the activity then complete the online post test and evaluation by March

12, 2015. To complete the online post test and evaluation, participants must have a

valid Pharmacist.com user name and password. A Statement of Credit will be

automatically be generated upon achieving these requirements.

NOTE: no voucher code is needed when completing the online version of this

course

4 4

Disclosures

• Dr. Touchette has received grant funding from Medco Health

Solutions for research projects related to improving medication

adherence

• Dr. Tilton has received consulting fees from Medco Health

Solutions for presentations related to improving medication

adherence

5 5

Learning Objectives

• At the completion of this program, participants will be

able to:

– Describe causes and effects of medication nonadherence.

– Identify tools and strategies for assessing medication

adherence.

– Explain the relationship between medication adherence and

health care quality measures for the prevention and

treatment of diseases.

– Discuss strategies to overcome barriers to medication

adherence for patients including motivational interviewing.

6 6

Please note your answers to the self-assessment questions on a piece of

paper. The questions and answers will be reviewed at the end of the

presentation.

After 12 months of therapy, what

proportion of days do patients taking

lipid lowering medications have those

medications “on hand” (i.e. have

enough days supplied to cover)?

audience response

A. 15% 2

B. 30% 11

C. 60% 10

D. 80% 0

7 7

Which of the following is not a

tool for assessing medication

adherence?

audience response

A. Med Take 3

B. TIMER 6

C. Morisky 8-item index 5

D. AIMS 10

8 8

Assuming each fill in the figure

below is for 30 days, which of the

following is the correct calculation

for medication possession ratio?

audience response

A. 120 / 180 = 67% 9

B. 60 / 130 = 46% 1

C. 90 / 130 = 69% 6

D. 90 / 180 = 50%

9 9

Which of the following best

describes motivational

interviewing?

audience response

A. It is used to persuade patients to

implement healthful behaviors 3

B. It is a “tough love” approach

to behavior change 0

C. It is designed to stimulate a

patient’s intrinsic motivation to change 23

10 10

Which of the following

statements is false?

audience response

A. Patients’ adherence can be measure

by either proportion of days covered or

medication possession ratio 6

B. Motivational interviewing is most

useful when a patient is in the “action”

stage of change 17

C. Patients with asymptomatic

conditions are less likely to adhere

to their medications 3

D. Poor adherence is estimated to

result in $100 billion in avoidable

hospitalization costs 1

11 11

Index

• Medication Adherence and Impact on Health

• Tools and Strategies for Assessing Adherence

• Tools and Strategies for Addressing Adherence

Issues

• Case Studies

• Pharmacists Roles in Improving Adherence

• Medication Adherence and Quality Measures

• Question and Answer

12 12

Drugs don’t work in patients who don’t take them.

C. Everett Koop, M.D.

13 13

Adherence vs. Persistence

• Medication Adherence (Compliance):

– The extent to which patients take medications as

prescribed by their health care providers

– Compliance suggests patient passively following

directions

– Adherence implies an agreement

• Persistence

– Time of continuous therapy, demarcated by the time from

initiation to discontinuation of therapy

Osterberg et al. N Engl J Med 2005; 353: 487-97.

Cramer et al. Value Health 2007; 11: 44-47.

14 14

Patient Adherence to

Medications

• Poor adherence and persistence are serious issues

in healthcare

– Assessing lipid lowering medications in a Medicare cohort

(n=34,501)

• Patients had medications “on hand” (MPR) for only

60% of the time in the first year of therapy

• 34-39% had medications “on hand” for more than 80%

of the time (i.e. adherent)

• 29% of patients failed to fill prescriptions after 3

months

– Drugs with bothersome side effects may be filled less

frequently or discontinued more often

– Cost: $100 billion on avoidable hospitalizations

Benner JS et al. JAMA. 2002;288(4):455-61.

Osterberg et al. N Engl J Med 2005; 353: 487-97.

15 15

Clinical Impact of Poor

Adherence

Sokol MC, et al. Med Care. 2005;43(6):521-30.

16 16

Economic Impact of Poor

Adherence: Medication Costs


17 17

Economic Impact of Poor

Adherence: Total Costs


18 18

• Analysis of 1705 Medicaid patients with type 2

diabetes

– 37% of patients were adherent (MPR > 80%)

– Adherent patients had

• Lower risk for hospitalizations (OR = 0.80)

• Lower risk for ED visit (OR = 0.71)

• 15% lower total medical costs

• 12% lower hyperlipidemia medical costs

Predictors of Higher

Healthcare Costs

Wu et al. Ann Pharmacother. 2011 45(3): 342-349.

19 19

Work-related Economic Impact

of Poor Adherence

• Retrospective, observational study (n=2112)

• New episode of treatment with

antidepressant

– Characterized as “adherent” or “non-adherent”

according to HEDIS criteria

– Acute phase: 84/114 days

– Continuation phase: 180/231 days

Burton WN et al. Am J Manag Care. 2007;13(2):105-12.

20 20

Work-related Economic Impact

of Adherence

Burton WN et al. Am J Manag Care. 2007;13(2):105-12.

21 21

Index




Issues

• Case Studies




22 22

Identified Predictors of

Nonadherence

• Presence of barriers to care or medications

• Cost of medication, copayment

• Treatment complexity

• Psychological problems / depression

• Cognitive impairment

• Asymptomatic disease

• Inadequate follow-up / discharge planning

• Side effects of medication

• Lack of belief in treatment benefit

• Lack of insight into illness

• Poor provider-patient relationship

• Missed appointments

McDonald HP et al. JAMA. 2002;288(22):2868-79.

Gherman A et al. Diabetes Educat. 2011; 37(3): 392-408.

Gellad WF et al. Am J Geriatr Pharmacother. 2011; 9: 11-23.

23 23

Impact of Medication Choice

on Adherence

0

0.5

1

1.5

2

2.5

3

Multiple Thiazides Betablock

Other CCB ACEInhib

RR

fo

r A

dh

eren

ce

Monane. AJH 1997;38(2):303-12.

24 24

Presence of CHF or CAD on

Adherence

0.8

0.9

1

1.1

1.2

1.3

1.4

No Yes

RR

fo

r A

dh

eren

ce

Monane. AJH 1997;38(2):303-12.

25 25

Impact of Number of Pharmacies

Used on Adherence

0

0.2

0.4

0.6

0.8

1

1.2

One More than one

RR

fo

r A

dh

eren

ce

Monane. AJH 1997;38(2):303-12.

26 26

Reasons for Poor Medication

Adherence

External:

System and Health

Barriers

Cognitive

Factors

Internal:

Behavioral Factors

and Beliefs

Touchette. Pharmacotherapy 2010 30(5): 425-427.

27 27

System and Health Related

Barriers

• Lack of coverage

• Complicated drug coverage

• High out-of-pocket costs

• Presence of depression

• Complicated regimen

• Drug adverse events

• Complicated or poorly

worded directions


28 28

Behavioral Factors and Beliefs

Ways people

evaluate

drug therapy

Drug taking

Drug therapy

and identity


29 29

Behavioral Factors and Beliefs

• Social support and interaction

• Busy schedule

• Poor patient-provider

relationship

• Beliefs about condition

• Beliefs about Western

medicine

• Beliefs about specific

medicine


30 30

Cognitive Factors

• Poor memory

• Difficulty understanding

directions / health literacy

• Ability to follow directions /

self-efficacy

• Physical limitations


31 31


Medications

• Poor adherence and persistence are impacted by

healthcare beliefs

– 4076 South Carolina Medicaid recipients 18 yo or over

• Overall, MPR was approximately 58%

– White patients: 61%

– Black patients: 55%

$0

$500

$1,000

$1,500

$2,000

$2,500

Mean DrugCosts

MeanHospitalCosts

Black Patients

White Patients

Dickson et al. Ethnic Dis 2008; 18: 204-209.

32 32

• Black patients more likely to perceive high blood

pressure as being “very serious” or “serious”

– So why lower adherence?

• Possible reasons for differences in adherence are

– Perception that medications are harmful and ineffective

• Non-Caucasian patients receive lower-cost

medications

• May experience more side effects

– Belief that hypertension and high blood pressure are

different disease models

– “Scare tactics” don’t work

– Patient-provider trust may not be established

– Increased comorbidities


Medications

Bosworth et al. Am J Med 2006; 119: 70.e9-70.e15.

Ogedegbe et al. Ethn Dis 2004; 14: 3 -12.

Lukoschek. J Health Care Poor Underserved 2003; 14: 566-587.

33 33

Assessing Adherence:

Methods

• Pharmacy records and claims data

• Patient interviews

– Patient estimates of adherence

• Pill counts

• Biological assays

• Weight of topical medications

• Electronic monitoring

34 34

Assessing Adherence:

Tools

• Raehl’s Med Take Interview

• TIMER DRP identification tool

• Morisky adherence index

35 35

MedTake

• Patient interview assessing:

– Demographics

– Medical history

– Medication history

– Current medication review

• Prescription

– Pillboxes or calendar boxes

– Notes from physician regarding changes to dosing

or directions (e.g. warfarin)

• OTC

• Herbal

– Recent medication changes

– Patients asked to open container and simulate taking the

drug

Raehl. Pharmacotherapy 2002; 22(10): 1239-48.

36 36

MedTake

Drug

Name,

dose, SIG

Subject’s

description

of how

he/she takes

the drug

Dose

(1, 0)

Indication

(1, 0)

Food, water

coingestion

(1, 0)

Regimen

(1, 0)

Score

(=total / 4)

Metoprolol

50mg

1 twice

daily

50mg

1 pt

No idea

0 pts

Water

1 pt

1 at 9am

1 at 6pm

1 pt

3 pts

(75%)

1 = correct, 0 = incorrect Raehl. Pharmacotherapy 2002; 22(10): 1239-48.

37 37

TIMER

• Designed for identifying and assessing DRPs

• Regarding adherence:

– Four questions

– Three recommendations

• Questions are worded in non-threatening way

– Give patient “permission” to have less than perfect

adherence

– Patient more likely to be open and honest

38 38

TIMER

1. Everyone forgets to take their medicines. How

often does this happen to you?

2. Everyone says that they miss a dose of their

medication or adjust it to suit their own needs.

How often do you do this? Why?

3. Has your physician told you to change how you

take any of your medications?

4. Has your physician told you to stop taking any of

your medications?

Lee et al. Am J Pharm Ed 2009; 73(3): Article 52.

39 39

Morisky 8-item

No = 0 Yes = 1

1. Do you sometimes forget to take your [health

concern] pills?

2. People sometimes miss taking their medications

for reasons other than forgetting. Thinking over the

past two weeks, were there any days when you did

not take your medicine?

3. Have you ever cut back or stopped taking your

medication...?

4. When you travel…?

5. Did you take your medicine yesterday?

6. When you feel like your [health concern] is under

control, do you sometimes stop…?

7. Taking medication everyday is a real

inconvenience for some…

40 40

Morisky 8-item

8. How often do you have difficulty remembering to

take all your medications?

Never/rarely

Once in a while

Sometimes

Usually

All the time

Morisky et al. J Clin Hypertens 2008; 10(5):348-354

41 41

Index




Issues

• Case Studies




42 42

Addressing Medication

Adherence

Number one predictor of a patient’s medication adherence is if they believe they have a healthcare provider that

cares about them

-Bruce Berger, PhD

43 43

Tools and Strategies for

Addressing Adherence Issues

• Cognitive Factors • Poor memory

• Difficulty understanding directions / health literacy

• Ability to follow directions / self-efficacy

• Physical limitations

• Possible Adherence Solutions – Count out doses in advance

– Keep a checklist

– Use a beeping alarm

– Put dosage time in daily planner

– Arrange for privacy

– Keep a diary

– Leave notes and reminders

– Establish and use support network

44 44



• System and Health • Lack of coverage

• Complicated drug coverage

• High out-of-pocket costs

• Presence of depression

• Complicated regimen

• Drug adverse events

• Complicated or poorly worded directions

• Possible Adherence Solutions • Patient assistance programs

• Sample

• $4 generics

• Talking with doctor

• Discuss with patient what is will work for them

45 45



• Behavioral Factors and Beliefs • Social support and interaction

• Busy schedule

• Beliefs about condition

• Beliefs about Western medicine

• Beliefs about specific medicine

• Poor patient-provider relationship

• Possible Adherence Solutions • Educate family and caregivers

• Work with patient’s life to help identify a regimen for them

to remember

• Educate the patient-verbal and written

• Motivational Interviewing

46 46

They speak of my drinking, but never of my thirst.

-Scottish Proverb

47 47

Addressing Adherence

• Typical Challenges

– Communication is NOT patient-centered

– The pharmacist is trying to save the patient

– Labeling the patient

– Dictate behavior change

• Build a pharmacist-patient relationship

• Use Motivational Interviewing (MI)

48 48

What is Motivational

Interviewing?

Patient-centered, evidenced-based

counseling approach that is

specifically designed to enhance

motivation to change among

patients not ready to change

Miller, W.R., Rollnick, S., Motivational Interviewing , 2nd

edition. NY: The Guilford Press, 2002.

49 49

Why use Motivational

Interviewing?

• Understand patient’s frame of reference

• Express acceptance & affirmation

– No face loss

• Spirit is “unconditional acceptance”

– Love, caring and collaboration

• Monitor patient's degree of readiness to

change

• Affirm patient's freedom of choice & self-

direction Rollnick, Mason, Butler. Health Behavior

Change. A Guide for Practitioners. Churchill

Livingstone: Elsevier, 1999. Print

50 50

DiClemente and Prochaska’s

Stages of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

P

r

o

g

r

e

s

s

R

e

l

a

p

s

e

Rollnick, Mason, Butler. Health Behavior Change. A Guide for

Practitioners. Churchill Livingstone: Elsevier, 1999. Print

51 51

Motivational Interviewing

Principles

• Decisional Balance – PharmD’s job is to tell the patient the risks of not changing

their behavior…not to “fix” them.

– Tilt balance towards favor of benefit by asking how the risks would affect their life.

– PharmD can inform them, but not make them change.

Rollnick, Mason, Butler. Health Behavior Change. A

Guide for Practitioners. Churchill Livingstone: Elsevier,

1999. Print

52 52


Principles

• Resistance

– 2 types

• Issue: “I’m not ready to take my insulin, I’m fine.”

• Relational: “I told you; I’m just not ready to take my

insulin!”

– Pharmacist’s role is to reduce resistance by

rolling with it….explore don’t explain

– DO NOT PERSUADE!

Rollnick, Mason, Butler. Health Behavior



53 53


Principles

• Do you dance or wrestle with your

patients?

Rollnick and Miller, 2001

54 54


Principles

• Express empathy

– Skillful, reflective listening

– Ambivalence is normal




55 55


Principles

• Support self-efficacy

– The patient’s belief in the possibility of change is an

important motivator

– The pharmacist’s belief in the patient’s ability to change

becomes a self-fulfilling prophecy


Change. A Guide for Practitioners.

Churchill Livingstone: Elsevier, 1999. Print

56 56


Principles

• Develop discrepancy

– This should come from the patient rather than the

pharmacist

– Change is motivated by a perceived discrepancy between

the patient’s current behavior and their personal goals and

values


Guide for Practitioners. Churchill Livingstone:

Elsevier, 1999. Print

57 57


Tools

• What if scenarios – “What would it look like if….”

• The envelope – “What would the message inside this envelope have to

say for you to….”

• Insurance card – “Can I tell you what concerns me?”

58 58


Skills

• Get permission

• Open-ended questions

• Reflective listening

• Summarizing

59 59

MI Flow Basics

• Develop a relationship – Create a rapport

– Develop an atmosphere that is safe for the patient

• Non-defensive

• Can talk openly and honestly without being judged

– This will help make the patient open their thinking

Rollnick, Mason, Butler. Health Behavior Change.

A Guide for Practitioners. Churchill Livingstone:


60 60

MI Flow Basics

• Develop a relationship – Express empathy

• Skillful, reflective listening

– Support self-efficacy

• The patient’s belief in the possibility of change is an important motivator

• The patient is responsible for choosing to change and carry it out

• The pharmacist’s belief in the patient’s ability to change becomes a self-fulfilling prophecy




61 61

MI Flow Basics

• Evaluate the patient’s reasoning

– Recognize the patient’s core issues

– Reflect and empathize with core issues

– Examine the reasoning behind each issue

– Address the weakness in each point of faulty

reasoning

– Encourage the pt to draw a new conclusion


Guide for Practitioners. Churchill Livingstone:


62 62

MI Flow Basics

• Use reflective listening to give clear evidence that

you have heard the patient’s issue

– Feeling + content + reasons

– Avoid: “I understand that….”

63 63

MI Flow Basics

Reflective listening to identify the core issue:

Pt: “It’s really hard to remember take my medication every morning. I am too busy trying to get the kids and my husband dressed and fed before they leave for the day.”

PharmD: “It sounds like your mornings can be really hectic and stressful, which does allow time for you to take your medication.”

64 64

MI Flow Basics

Reflective Listening to support self-efficacy and empathy:

Pt: “I’m shocked that my lipids didn’t come down a lot more b/c I’ve lost weight…..I’ve been really watching what I’m eating.”

PharmD: “It’s great that you’ve been able to lose weight. Tell me how you’ve managed to do that.”

65 65

MI Flow Basics

• Need to make sure there is a transition from

evaluating their reasoning to informing the patient.

• Patients can misunderstand questions as

accusatory

• Need to create a direct connection back to the

shared understanding of the patient’s issue.

66 66

MI Flow Basics

Example of transition:

Pt: “I don’t think I need to take my Lipitor anymore, my cholesterol is fine and I’ve heard it can harm my liver and cause muscle pain.”

PharmD: “It sounds like you’re wondering whether you still need to take your Lipitor because your cholesterol has been controlled and the medication could cause side effects. In order for me to address your concern about the medicine, may I ask you some questions?”

Pt: Sure.

67 67

MI Flow Basics

• Explore the patient’s reasoning

• Identify influences in the patient’s line of reasoning

68 68

MI Flow Basics

• Address line of reasoning – Add new information

– Correct misinformation

– Address understated statements

• “I feel fine.”

– Personalize benefits/losses

– Create discrepancies

– “Insurance Card”

69 69

MI Flow Basics

• Have patient make a conclusion

– Don’t pressure the patient

• “That’s why we want you to…”

– Implying only one conclusion

• “Would you be willing to try…”

– This is a yes or no question

• “What are your thoughts about this information?”

• “How do think this information applies to you?”

70 70

MI Flow Basics

• Have patient make a conclusion

– Goal is to avoid creating relational resistance

– Want to assist the patient in make their own argument for

change

– If they aren’t ready, back off

71 71

MI Flow Basics

• Gauge willingness, readiness and confidence to change

– Reinforce change talk and any changed conclusions

– Examine what the patient is willing and ready to do

Example

PharmD: “Cutting back on your fruit juice intake will help reduce your blood sugars. How do you think you can go about cutting back?”




72 72

MI Flow Basics

• Close the deal

– Summarize patient’s line of reasoning

– Express desire to help the patient in reach their

goal

– Acknowledge self-efficacy of any change

suggested by the patient

– Identify future interactions with the patient

73 73

Index




Issues

• Case Studies




74 74

Case Video

75 75

Case

MB is a 49 year old Caucasian female for who you

are performing a comprehensive medication review.

PMH:

DM

HTN

Medications:

• Metformin 1000 mg, 1 tab po twice daily.

• Aspirin 81 mg, 1 tab po daily.

• Carvedilol 25 mg, 1 tab po twice daily.

• Enalapril 20 mg, 1 tab po twice daily.

• Amlodipine 10 mg, 1 tab po daily.

• Hydrochlorothiazide 25 mg, 1 tab po daily.

76 76

Case

Upon further review and assessing how she is taking her medication, the patient states that she hasn’t filled carvedilol, enalapril, amlodipine, or hydrochlorothiazide for over two months.

She states that her life has been very stressful, taking care of 3 teenagers. She also states that she isn’t able to afford all of her medication and has been taking them only once in a while but has now run out.

You ask permission to discuss her adherence issues.

77 77

Case

• What is the patient’s reason(s) for nonadherence to

her medications?

– Stress and cost

• What questions should we ask about her

nonadherence?

– Tell me your understanding about why you are taking

these medications?

– Tell me what you know about HTN and DM?

– How do you feel when you don’t take your medications

and how do you feel when you do take all of your

medications?

– What are your healthcare goals?

78 78

Case

• Patient’s responses

– Tell me your understanding about why you are taking

these medications?

• “For high blood pressure and diabetes.”

– Tell me what you know about HTN and DM?

• “I don’t know, I feel fine….my doctor said they can

cause bad things to happen if I don’t take my

medication.”

79 79

Case

• Patient’s responses continued

– How do you feel when you don’t take your medications

and how do you feel when you do take all of your

medications?

• “I feel fine if I don’t take my medications, but get really

dizzy when I take all of them.”

– What are your healthcare goals?

• “To feel good and not have the bad things happen

because of my diabetes and blood pressure.”

80 80

Case

• What additional barriers did we discover about her

nonadherence?

– Lack of belief in treatment benefit

– Lack of insight into illness

– Side effects - dizziness

81 81

Case

• What tools can we use to address her adherence?

– Motivational interviewing

• Assess motivation to change – probably preparation to

action phase

– Education

• About diabetes and hypertension

• About medications

– Establish and use support network, if possible

– Evaluate how much she can afford each month

– Involve her physician

• Evaluate if all medications are necessary if she takes them – dizziness

– Follow-up!

82 82

Index




Issues

• Case Studies




83 83

Chronic Care Model

Community Health Systems

Self

Management

Support

Delivery

System

Design

Decision

Support

Clinical

Information

Improved Outcomes

Informed,

Activated

Patient

Prepared,

Proactive

Practice Team

Adapted from http://www.improvingchroniccare.org/index.php?p=the_chronic_care_model&s=2.

84 84

Chronic Care Model

Community Health Systems

Self

Management

Support

Delivery

System

Design

Decision

Support

Clinical

Information

Improved Outcomes

Informed,

Activated

Patient

Prepared,

Proactive

Practice Team

85 85

Self Management Support

• Motivational interviewing

• Information / education

– Medication education

– Disease state educator

• Improve patient self-efficacy

86 86

Delivery System Design

• Help patient navigate complex health system

– Follow-up liaison - continuity of care

– Ensure medications can be obtained by the patient based

on cost and/or formulary

– Prior approvals

• Suggest improvements to work flow

– Create collaborative agreements or standing orders

• Break down barriers to patients receiving care

– Be an active part of ACO/Medical Home

87 87

Decision Support

• General Provider Education

– Keep nurses and physicians up to date on medication

literature and on-going trials

• Patient-specific Recommendations

– Therapy recommendations

– Drug monitoring recommendations

– Prevent adverse drug events

– Prevent drug interactions

88 88

Clinical Information

• Generate New Information to Improve Care

– Medication reconciliation

• Provide Timely Information / Review and Interpret

Literature

– Drug information center

– Clinical practice

89 89

Index




Issues

• Case Studies




90 90

Quality Measures for

Programs

• Measure adherence using prescription claims data

– Medication Possession Ratio (MPR)

– Proportion of Days Covered (PDC)

– Adjustment for hospitalization

• Issues:

– Cash generic medications

– Lag in claims

– Multiple drugs

– Drug switching

– Overlapping fills

– Non-persistent patients

– Prescriptions returned to stock

– 90-day fills

– Can have over 100% adherence (MPR)

91 91

Medication Possession Ratio

• Number of days medication supplied in a given

interval

• Numerator is the sum of the days supplied from the

first fill in period to the second last fill in the period

• Denominator is date of the last fill minus the date of

the first fill

Days supplied in the period

Days in the period =

92 92


Claim 1

Claim 2

Claim 3

Claim 4

Claim 5

Study Period Begins Study Period Ends

Day 1-30 Day 31-60 Day 61-90 Day 91-120 Day 121-150 Day 151-180

4 x 30

150 = = MPR 80%

93 93


• Multiple drugs (dual or triple therapy)

Days supplied in the period / number of drugs


• If the days in period are different for each

medications:

– Average the MPR for all medications for a condition

94 94


Claim 1

Claim 2

Claim 3

Claim 4

Claim 5

Claim 1

Claim 2

Claim 3

Claim 4



(3 x 30)

150 = = MPR2 60%

MPR1 = 80%

MPR = (80% + 60%) / 2 = 70%

95 95

Proportion of Days Covered

• Similar to MPR for a single medication

– Values range from 0 to 1

• Conservative estimate of medication adherence

compared to MPR for multiple medications

– A day is counted if ALL MEDICATIONS are available on

that day

Days drugs are available


96 96

Proportion of Days Covered

Claim 1

Claim 2

Claim 3

Claim 4

Claim 5



140

180 = = PDC 77.8% Method 1:

150

180 = = PDC 83.3% Method 2:

97 97

MPR vs. PDC for Multiple

Medications

Claim 1

Claim 2

Claim 3

Claim 4

Claim 5

Claim 1

Claim 2

Claim 3

Claim 4



90

180 = = PDC 50%

MPR = 70%

98 98

Index




Issues

• Case Studies




99 99

Key Points

• Nonadherence can increase healthcare costs,

decrease patient productivity and quality of life

• Nonadherence happens for a multitude of reasons

• Nonadherence must be managed on an individual

basis

• Nonadherence requires a patient-centered

approach

• Pharmacists have the resources to identifying the

root cause of the patient’s nonadherence and how

to address those issues

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After 12 months of therapy, what

proportion of days do patients taking

lipid lowering medications have those

medications “on hand” (i.e. have

enough days supplied to cover)?

audience response

A. 15% 0

B. 30% 1

C. 60% 13

D. 80% 8

101 101

Which of the following is not a

tool for assessing medication

adherence?

audience response

A. Med Take 2

B. TIMER 1

C. Morisky 8-item index 0

D. AIMS 25

102 102

Assuming each fill in the figure

below is for 30 days, which of the

following is the correct calculation

for medication possession ratio?

audience response

A. 120 / 180 = 67% 7

B. 60 / 130 = 46% 3

C. 90 / 130 = 69% 14

D. 90 / 180 = 50% 2

103 103

Which of the following best

describes motivational

interviewing?

audience response

A. It is used to persuade patients

to implement healthful behaviors 1

B. It is a “tough love” approach

to behavior change 0

C. It is designed to stimulate a

patient’s intrinsic motivation to change 27

104 104

Which of the following

statements is false?

audience response

A. Patients’ adherence can

be measured by either proportion

of days covered or medication

possession ratio 0

B. Motivational interviewing is most

useful when a patient is in the “action”

stage of change 23

C. Patients with asymptomatic conditions

are less likely to adhere to their medications 2

D. Poor adherence is estimated to result

in $100 billion in avoidable hospitalization costs 0

to view the slides - american pharmacists association

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