Adherence

Direct assessment

• Lab tests • Direct observation • Downsides - Costly - Invasive - Impractical

Beliefs About Medicines Questionnaire: Concerns

• "I sometimes worry about the long term effects of my medicines." • "I sometimes worry about becoming too dependent on my medicines." • More...

Beliefs About Medicines Questionnaire: Necessity Beliefs

• "My health, at present, depends on my medicines." • "My medicines protect me from becoming worse." • More...

Basic Interview/Questionnaire

"I know it can be difficult to take all your medications regularly. How often do you miss taking them?"

Recipients of services

*Populations* - Public health role - Looking at problems at a group level - Interventions targeted at group *Individuals* - Clinical role - Looking at problems at an individual level - Interventions targeted at individual

ECHO

- *E*conomic - Costs - *C*linical - Medical events - *H*umanistic - Health‐related quality of life and patient satisfaction -- *O*utcomes targeted by services

Interventions: Too many medications or too many doses

- Adherence aids - Reduce number of medications • Eliminate unnecessary medications • Combination medication - Reduce dose frequency • Switching medication • Long‐acting agent - Motivational interviewing

Reasons for Intentional nonadherence

- Adverse effects - Beliefs • Examples - Should stop occasionally to maintain effect - Think the drug is not helping - Feel they are taking too much medication

Interventions: Cost

- Cheaper medication - Pharmaceutical assistance programs - Different plan - Tablet splitting - Reduce number of medications - Combination medications

Interventions: Poor patient‐provider relationship or poor provider communication

- Communicate with patient about condition and medication - Provide encouragement to patient - Acknowledge successes - Discuss patient concerns - Involve patient in treatment decisions

Interventions: Administering medication:

- Easy open lids - Pre‐cut tablets - Smaller tablets, liquids, transdermal - Crushable tablets or capsules that can be opened

Medication‐related action plan (MAP)

- For patient use - Contains list of actions for patient - Patient uses to track progress - Encourages patient participation in care

Reasons for Unintentional nonadherence

- Forget - Physically unable - Poor understanding of drug regimen - Drug not available

Health care system Contribution to Nonadherence

- Formularies - High costs for drugs - Unavailability of drugs

Persistence

- Length of time from starting therapy to stopping therapy - Does patient continue with therapy as long as provider intended?

Types of Unintentional nonadherence

- Miss occasional dose - Take more than prescribed - Take medication intermittently

Intentional nonadherence

- Missing or altering doses to suit one's needs • Active decision • Driven by Beliefs and motivation

Interventions: Low self‐efficacy or Lack of motivation

- Motivational interviewing - Motivational interviewing

Interventions: Side effects

- Motivational interviewing - Patient education • Expectations • Management - Different medication

Types of Intentional nonadherence

- Never fill the medication - Take medication regularly but alter timing or dose - Take medication less or more frequently than prescribed - Take medication intermittently - Stop medication before provider intends

Interventions: Do not see benefit in medication or do not think they need medication

- Patient education - Motivational interviewing

Intervention and/or referral

- Pharmacist provides consultation - Intervenes to address medication-related problems - Refers patient to another healthcare provider if necessary

Provider Contribution to Nonadherence

- Prescribe complex regimens - Fail to explain benefits and side effects adequately - Not clearly explaining how to use medication - Not giving consideration to cost of medication - Poor therapeutic relationship with patients

Documentation and follow‐up

- Services documented in consistent manner - Schedule follow‐up visit based on patient's medication‐related needs

Morisky Medication Adherence Scale

1. Do you ever forget to take your medicine? 2. Are you careless at times about taking your medicine? 3. When you feel better do you sometimes stop taking your medicine? 4. Sometimes if you feel worse when you take the medicine, do you stop taking it?

Adherence Estimator

1. I am convinced of the importance of my prescription medication. 2. I worry that my prescription medication will do more harm than good to me. 3. I feel financially burdened by my out‐ofpocket expenses for my prescription medication.

Personal medication record (PMR)

Complete record of patient's medications • Prescription medications • Nonprescription medications • Herbal products • Dietary supplements

How do we decide whether someone is nonadherent to a medication?

Could say nonadherence is any deviation from what was prescribed - Usually not that strict • 80% is often used as cut-point • Choice depends on what is clinically relevant - Nonadherence in HIV

Reducing nonadherence

Even though strategies to tackle nonadherence... Can be difficult to change

Adherence

Extent to which a person's behavior coincides with medical or health advice Extent to which dose, frequency, and timing of medication matches what was prescribed Other terms - Compliance

Interventions

Interventions • Nonadherence is multifactorial • To improve adherence, have to target their specific reasons for being nonadherent • Some interventions target a single factor, others target multiple factors

Unintentional nonadherence

Missing or altering doses because of forgetfulness, errors in understanding or mistakes

Concordance

Patient and provider reach agreement about therapeutic goals and treatment - Decisions incorporate both patient and provider views

Medication Therapy Management (MTM): Objectives:

Promote safe and effective medication use Achieve optimal patient outcomes • Separate from dispensing • Patient‐centered care - Evaluation of all medications taken - Does not revolve around a product

Interventions:

Reminders: - Calendars - Phone calls - Electronic devices • MD2 • Programmable watches - Text messages • Medication organization - Pill organizers • www.forgettingthepill.com • www.epill.com - Blister packaging (or unit‐of‐use packaging)

Medication therapy review (MTR)

Systematic process Collect patient information Assess medication therapy to identify medication related problems Develop list of medication‐related problems Create plan to resolve medication‐related problems

Patterns of nonadherence

• Close to perfect adherence • Nearly all doses but some incorrect timing • Occasionally miss dose and some incorrect timing • Occasionally miss dose and drug holidays 3‐4 times/year • Frequently miss dose and drug holidays 1 time/month • Miss most doses

Populations

• Conducting population analysis of medication patterns • Participating in formulary management • Developing drug programs providing support for at‐risk populations (such as patients using warfarin) • Developing disease prevention programs

Reasons patients give for not adhering to their medications

• Cost • Side effects • Didn't think drug would help • Didn't think they needed it • Drug didn't help • Don't like taking medications • Condition improved • Take too many medications

Why should we be concerned about nonadherence?

• Cost of medication nonadherence each year in the US - *$100‐$300 billion* - *10% of hospital admissions* in older adults - *23% of nursing home admissions* - *125,000 deaths*

Adherence assessments

• Direct assessment • Indirect assessment

Individuals

• Education and counseling • Health screening • Assessing clinical parameters • Disease state management • Medication therapy management

Reasons patients give for not adhering to their medications

• Forgetfulness • Other priorities • Decision to omit dose • Lack of information • Emotional factors

Reasons patients give for not adhering to their medications

• General concerns about medication • Wanted to try lifestyle modification instead • Fear of side effects • Didn't think medication was needed • Didn't think condition was life threatening • Fear of drug interactions • Didn't want to take any more medications

Indirect assessment

• Interview/Questionnaire • Diaries • Assess whether response to therapy • Pharmacy records/prescription claims • Medication counts • Electronic monitors

Reasons patients give for not adhering to their medications

• Medication didn't work as expected • Learned to get by without medication • Side effects • Cost • No longer having symptoms • Don't like taking medications for too long • Don't like taking any medications • Insurance changed • Don't think doctor made right treatment decision • Advice from family/friend

Medication Therapy Management (MTM): Core elements

• Medication therapy review (MTR) • Personal medication record (PMR) • Medication‐related action plan (MAP) • Intervention and/or referral • Documentation and follow‐up

Types of nonadherence

• Never filling the prescription • Taking the incorrect dose • Incorrect timing of dose • Missing dose or extra dose • Stopping before provider intended

Interventions: Obtaining medication:

• Obtaining medication: - Pharmacy delivery - Mail order pharmacy

Are people nonadherent?

• Overwhelming evidence that people are nonadherent to medications • 30‐50% of people nonadherent to medication

Interventions

• Patient education • Counseling • Telephone calls • Reduce regimen complexity • Self monitoring • Reminders • Adapt regimen to routine • Blister packaging • Rewards • Direct observation • Pharmacist services

Implications of nonadherence

• Patients - Can prevent them from reaching goals • Providers - May not meet performance goals • Pharmacies - Less revenue • Drug companies - Less revenue • Payers - More expenses • Employers - Lower productivity

Transtheoretical Model

• Precontemplation • Contemplation • Preparation • Action • Maintenance

Proportion of Days Covered

• Total days supply/total number of days evaluated - Range from 0 to 1 - Cap at 1

Medication Possession Ratio

• Total days supply/total number of days evaluated • Can exceed 1