Understanding and Addressing Problematic Medication Adherence

William H. Polonsky PhD, CDENovember 10, 2017

whp@behavioraldiabetes.org

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HEDIS data from >1000 health plans covering >171 million lives

2005 2014

29.7% 31.1%OF ALL

PATIENTS WITH

DIABETES*

OF ALL PATIENTS

WITH DIABETES*

% OF DIABETIC PATIENTS WITH

VERY POOR GLYCEMIC CONTROL

(HbA1c >9%) IN THE US

National Committee for Quality Assurance. http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality.aspx. *In a commercial HMO population that includes either Type 1 or Type 2 diabetes.

RATES OF VERY POOR GLYCEMIC CONTROL

3

THE KEY BEHAVIORAL CONTRIBUTOR TO GLYCEMIC CONTROL?

SMBG, self-monitoring of blood glucose.aCovariates, age, gender, race, ethnicity, income, education, insurance status, insulin status and duration of diabetes. HbA1c assessed with a point-of-care device.bP<0.05Osborn CY, et al. J Clin Pharm and Ther. 2016;41:256-259.

0.06

-0.04 -0.03-0.002

-0.16-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.2

General Diet Specific Diet Exercise SMBG Medications

ALL SELF-CARE BEHAVIORS + COVARIATESa

4

Adhe

rent

Pat

ient

s at

Fol

low

-up

(%)

Full Study Population

DPP-4i SU TZD

42.0%47.3%

41.2% 36.7%34.6%

40.5%34.6%

27.9%

n=238,372; n=134,444

n=61,399; n=31,073

n=42,012; n=27,872

n=134,961; n=75,499

0

100

20

40

60

80

10

30

50

70

90

2-YEAR FOLLOW-UP1-YEAR FOLLOW-UP

ADHERENCE RATES FOR ORAL AGENTS ARE LESS THAN 50%

PDC, proportion of days covered; SU, sulfonylurea; TZD, thiazolidinedione.A retrospective claims analysis of 238,372 patients with T2D with at least 1 prescription claim for a DPP-4i, SU, or TZD from January 1, 2009 to January 31, 2012. Adherence defined as PDC ≥0.8.Farr AM et al. Adv Ther. 2014;31:1287-1305.

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AMONG 75,589 INSURED PATIENTS IN THE FIRST YEAR OF A COMMUNITY-BASED E-PRESCRIBING INITIATIVE

31%

TRACKING NEW E-PRESCRIPTIONS FOR DIABETES MEDICATIONS

Fischer MA et al. J Gen Intern Med. 2010;25:284-290.

Filled

Never Filled

6

7

BASAL INSULIN PERSISTENCEAT 12 MONTHS

n = 4804 T2D ‘s

Wei et al, 2014

8

0

10

20

30

40

50

60

≥80 60-79 40-59 20-39 0-19

Prob

abili

ty o

f Hos

pita

lizat

ion,

%

Adherence Level, %

39% increased risk of all-

cause mortalitydue to poor

adherence to oral

hypoglycemics2

Poor adherence defined as PDC <0.8

HOSPITALIZATION RISK INCREASES WITH HIGHER RATES OF POOR ADHERENCE1,2

IMPACT OF POOR ADHERENCE TO GLUCOSE-LOWERING AGENTS

Data was provided by a large, Medicare supplemental (MarketScan) database from July 1, 2009 to June 30, 2014. There were 123,235 patients with T2D aged ≥65 who received glucose-lowering agents. Comparisons between adherent (defined as PDC ≥80%) and poorly adherent (PDC <80%) were all statistically significant at P<0.001.1

1. Boye KS et al. 76th ADA Scientific Sessions. June 10–14, 2016. Poster 1221-P. 2. Ho PM et al. Arch Intern Med. 2006;166:1836-1841.

56%50%

45%41%

37%

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SO WHAT TO DO?

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Nieuwlaat et al, 2014

EFFECTIVENESS OF CURRENT INTERVENTION STRATEGIES

Cochrane review of 182 RCTs:“Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.”

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WHAT ARE WE MISSING?

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THE PRESUMED PROBLEM: FORGETFULNESS

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THE SOLUTION: ADDRESS FORGETFULNESS

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“Patient’ s medication beliefs, especially perceived needfor medication and perceived medication affordability,were strong predictors of unintentional non-adherence.”

Gadkari and McHorney, 2012

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WHAT WE HAVE BEEN MISSING

“The evidence presented here adds weight to the criticism of educational interventions that assume poor adherence is due to patients’ failings, either in knowledge or remembering to take drugs. The participants in the studies presented here did not simply have a knowledge deficit but held alternative explanations for their hypertension; many deliberately chose to avoid drugs.”

Marshall et al, 2012

16Polonsky and Henry, 2016

CRITICAL PATIENT BELIEFS ABOUT

MEDICATION (eg, perceived treatment

inefficacy, medication beliefs, and physician trust)

ADHERENCE

PATIENT-PERCEIVED MEDICATION BURDEN

(eg, obtaining/taking medication, treatment complexity, out-of-pocket

costs, and hypoglycemia)

PATIENT DEMOGRAPHIC

FACTORS(eg, younger age, lower education level and lower income level)

NON-PATIENT FACTORS(eg, lack of

integrated care in many healthcare systems, clinical

inertia among healthcare

professionals)

MAJOR CONTRIBUTORS

17Rosenbaum, 2015

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ROSENBAUM’S CONCLUSION

“It’s our job to help patients live as long aspossible free of CVD complications. Although most patients share that goal, we don’t always see the same pathways to get there.I want to believe that if patients knew what I know, they would take their medicine. What I’ve learned is that if I felt what they feel, I’d understand why they don’t.”

Rosenbaum, 2015

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201. Polonsky WH. J Diabetes. 2015;7:777-778. 2. Polonsky WH, Skinner TC. Clin Diabetes. 2010;28(2):89-92.

PERCEIVED TREATMENT INEFFICACY

Lack of tangible benefits contributes to discouragement and poor adherence

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COMPETING DEMANDS

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HYPOGLYCEMIC EVENTS AND HYPOGLYCEMIC FEAR

70%

56%46%

Adhe

rent

Pat

ient

s (%

)

Nohypoglycemia

n=80n=59n=266

0

100

20

40

60

80

10

30

50

70

90

Mildhypoglycemia

Moderate/worsehypoglycemia

Cross-sectional study of T2D patients in Sweden treated with metformin and a sulfonylurea. Adherence was determined using a self-report adherence and barriers questionnaire.3

1. Hajós TRS et al. Diabetes Care. 2014;37:102-108. 2. Gonder-Frederick LA et al. Diabet Med. 2013;30:603-609. 3. Walz L et al.Patient Prefer Adhere. 2014;8:593-601.

Reprinted from Patient Preference and Adherence, volume 8, L. Walz et al, “Impact of symptomatic hypoglycemia on medication adherence, patient satisfaction with treatment, and glycemic control in patients with type 2 diabetes” pages 593-601, Copyright (2014), with permission from Dove Medical Press Ltd.

WHEN PATIENTS EXPERIENCE HYPOGLYCEMIA, FEAR OF A FUTURE EVENT CAN LEAD TO SKIPPING OR DISCONTINUING MEDICATION.1,2

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CO-PAYS AND ORAL MEDICATIONS

Colombi AM, et al. J Occup Environ Med. 2008;50:535-541

% o

f Day

s M

edic

atio

n Ta

ken

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*Trust is defined using 2 items from the Trust in Physicians Scale (TIPS) modified to match the 4-point Consumer Assessment of Healthcare Providersand Systems (CAHPS) scale options during the preceding 12 months. †Shared decision-making was determined using 2 items from the Interpersonal Processes of Care (IPC) instrument during the preceding 12 months.

Differences in prevalence of poor refill adherence for any cardiometabolic medication in a cohort of 9377 patients with diabetes. Respondents were classified as poorly adherent when they had no medication supply for >20% of the observation time.

Ratanawongsa N et al. JAMA Intern Med. 2013;173:210-218.

Mea

n Ab

solu

te P

reva

lenc

e R

ates

of

Ref

ill A

dher

ence

(%)

Confidence/trust in PCP*

0

10

30

50

70

20

40

60

80

61%

72%65%

73%

62%

73%63%

72%

Involved you in decisions†

Understood your problems with treatment†

Put your needs first*

LOWER TRUST HIGHER TRUST

LACK OF PHYSICIAN TRUST

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Perceived worthwhileness: Does the patient believe the benefits of the medication outweigh the costs?

• Adverse effects

• Concerns about long-term adverse effects

• Represents “sickness”

• Rarely apparent

• HCP may state that long-term risks are reduced

PERCEIVED BENEFITS

PERCEIVED COSTS

Polonsky WH. J Diabetes. 2015;7:777-778.

MEDICATION BELIEFS

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Doesn't take any medications for T2D; his last HbA1c was 9.1%

WHO IS DOING

BETTERWITH HIS

DIABETES?

MEDICATION BELIEFS

Takes 2 oral medications for T2D and basal insulin; his last

HbA1c was 6.8%

ROY. How healthy you are, and your risk of complications, is not determined by how much medication you take.

It is your metabolic results that matter. Even if you are not taking pills or insulin, high blood

sugars will likely lead to future problems.Polonsky WH. J Diabetes. 2015;7:777-778.

ROY SAM

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WHY DO PATIENTS FEEL THIS WAY?

• Threatening patients with medication- “If you can’t make some positive changes, then

we’ll have no choice but to put you on more medication, and perhaps even start insulin.”

• Underlying messages- More medication should be avoided at all costs- You have failed- You are to be punished

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SO WHAT TO DO?1. Ask correctly

o “Any problems taking those medications?”

vs.o “What’s one thing about taking your

medications that’s been challenging?”

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SO WHAT TO DO?1. Ask correctly2. Forgetfulness

o “Aside from forgetting, what else is tough about taking your meds?”

o Anchoring strategies

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Anchoring Medication to Daily Events

Littenberg B, et al. BMC Fam Prac. 2006;7:1.

A1C

“A daily event (a meal, TV show, bedtime, brushing my teeth) reminds me.”

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SO WHAT TO DO?1. Ask correctly2. Forgetfulness3. Treatment complexity

o Simplify if possibleo Provide additional details as needed

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SO WHAT TO DO?1. Ask correctly2. Forgetfulness3. Treatment complexity4. Patient-provider trust

• Listen, listen, listen

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SO WHAT TO DO?1. Ask correctly2. Forgetfulness3. Treatment complexity4. Patient-provider trust5. Stay in touch

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The Value of Ongoing Contact

Arambepola et al, 2016

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SO WHAT TO DO?1. Ask correctly2. Forgetfulness3. Treatment complexity4. Patient-provider trust5. Stay in touch6. Talk about beliefs about diabetes and

medications

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Challenging Harmful Beliefs• Out-of-control diabetes can harm you,

even if you feel okay• Treatment should not be delayed

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Back on Track Feedback Name: Molly B.

Tests Usual Goals

Your Results FID #:

Your score should be

SAFE: At or better than goal

NOT SAFE: Not

yet at goal

A1C 7.0% or less 8.7% x

Blood Pressure 130/80 125/75 x

Lipids 100 or less 116 x

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Challenging Harmful Beliefs• Out-of-control diabetes can harm you,

even if you feel okay• Treatment should not be delayed

• Discuss the critical “medication secrets”

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Four Medication “Secrets”1. Taking your meds is one of the most powerful

things you can do to positively affect your health

2. Your meds are working even if you can’t feel it

3. Needing more medication isn’t your fault

4. More medication doesn’t mean you are sicker, less medication doesn’t mean you are healthier

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Addressing Insulin MisbeliefsObstacles Discuss

It means I have failed with my treatment

• No matter what you do, you may need it, because diabetes is “progressive”

Will wreck my quality of life • Short-term benefits include better sleep, mood and energy,

Insulin will cause long-term complications

• Investigate and challenge this belief • Insulin is much more likely to reduce

than raise complications risk

Needing more insulin wouldmean I’m sicker

• “More insulin doesn’t mean you are sicker or are in more danger. We are merely trying to figure out the right amount for your body.”

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CONCLUSIONSPoor medication adherence:• … explains a great deal of the lack of

glycemic progress over the past decade• … is commonly an attitudinal issue, not just

a behavioral issue.• … is best addressed by considering the

patient’s perspective, and encouraging a two-way conversation about the perceived pro’s and con’s of the medication.

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Further Reading• Brunton SA, Polonsky WH (2017). Medication

adherence in type 2 diabetes mellitus: Real-world strategies for addressing a common problem. Journal of Family Practice, 66, S46 –S51.

• Polonsky WH, Henry RR (2016). Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence, 10: 1299 – 1307.

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Thanks for Listening

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