Medication Adherence Issues

Which intervention has the most positive impact on medication adherence? a.) regimen simplification b.) adherence devices c.) oral education and counseling d.) Comprehensive management

d.) Comprehensive management

For the REALM-R, what score is considered at risk?

score of 6 or less

Describe the Indian Health Service Model.

1.) 3 Prime questions 2.) final verification

What can we do to increase adherence? (things to remind patients)

1.) Devices (Pillbox: Daily, weekly, monthly) 2.) Dial vial 3.) Alarm watches 4.) Key ring 5.) Beeper services 6.) Email reminders

What are some other barriers to adherence?

1.) Distrust in health care or lack of relationship 2.) Language Barriers 3.) Lack of follow-up 4.) Financial concerns 5.) Forgetfulness 6.) Psychiatric/Neurological conditions 7.) Physical Conditions Barriers

What are the 6 questions that are asked for the Morisky test? (M)= Motivation (K)= Knowledge

1.) Do you ever forget to take your medications? (M) 2.) Are you careless at times about taking your medicine? (M) 3.) When you feel better do you sometimes stop taking your medicine? (K) 4.) Sometimes if you feel worse when you take you medicine, do you stop taking it? (K) 5.) Do you know the long-term benefit of taking your medicine as told to you by your doctor or pharmacist? (K) 6.) Sometimes do you forget to refill your prescription medicine on time? (M)

What are some personal factors affecting adherence?

1.) Emotional State 2.) Health Beliefs 3.) Social Support 4.) Socioeconomic status 5.) Feeling about Dz, self-efficacy & outcomes

What does the REALM-R look at?

1.) Examiner sensitivity 2.) Visual acuity 3.) Pronunciation 4.) Dialect, accent or articulation problems

What are the 11 REALM-R words?

1.) Fat 2.) Flu 3.) Pill 4.) Allergic 5.) Jaundice 6.) Anemia 7.) Fatigue 8.) Directed 9.) Colitis 10.) Constipation 11.) Osteoporosis

What are the three case management adherence guidelines?

1.) Health Literacy 2.) Medication Knowledge 3.) Modified Morisky

How and why do patients fail to comply?

1.) Increasing dosage 2.) Drug "Holiday" 3.) "Whitecoat" compliance 4.) Refusal to take medication 5.) Discontinuation 6.) Reducing dosage

What are the two types of Non-Adherence?

1.) Intentional 2.) Unintentional

What questions are asked in order to determine Medication Knowledge?

1.) Name of medication 2.) Why is the medication being taken? 3.) How much medication are to be taken each time? 4.) When is the medication being taken? 5.) What effects should the patient be looking for? 6.) Where is the medication being kept? 7.) When is the next refill due?

What are some examples of Non-Adherence?

1.) Not having the prescription filled 2.) Taking the incorrect dose 3.) Taking the medicine at the wrong time 4.) Forgetting to take one or more doses 5.) Stopping the medication too soon

why do patients fail to comply by reducing dosage?

1.) Patient not convinced of drug's benefit 2.) Intolerance of adverse effects 3.) Cost

why do patients fail to comply by taking drug "holiday"?

1.) Patient not convinced of drug's benefit 2.) To achieve effect perceived as enjoyable 3.) To accommodate a transient life event 4.) Perception that drug interferes with certain events 5.) Inability to remember

why do patients fail to comply because of "Whitecoat" compliance?

1.) Patient not convinced of drug's benefit 2.) To procure approval from clinician or avoid rebuke

why do patients fail to comply by discontinuing medication?

1.) Patient not convinced of drug's benefits 2.) Intolerance of adverse effects 3.) Patient cannot remember to take drug 4.) Cost

why do patients fail to comply by refusing to take medication?

1.) Patient not convinced of need for drug 2.) Fear of adverse/side effects 3.) Cost 4.) Dislike of taking drugs

Why do patients fail to comply by increasing dosage?

1.) Perception that more is better 2.) Perception that drug makes the patient feel good 3.) To "hurry" the cure or treatment process

What are some barriers to adherence that are Medication/Therapy Related?

1.) Polypharmacy 2.) Complex regimens 3.) Lack of understanding benefits 4.) Side effects outweigh benefits 5.) Does not seem "to work" 6.) No effect 7.) Method of Administration

What are some treatment factors affecting adherence?

1.) Reason for Therapy 2.) Schedule 3.) Cost 4.) Evidence of benefits 5.) Adverse Effects

What are some interactions with system that affects adherence?

1.) Relationships with providers 2.) Satisfaction with Care 3.) Insurance coverage 4.) Convenience of Clinic

What are the three prime questions?

1.) What did your doctor tell you this medication was for? 2.) How did your physician tell you to take this medication? 3.) What did your doctor tell you to expect?

How can we help improve adherence?

1.) improve pharmacist-patient relationship 2.) Communication 3.) Education 4.) Implement plan 5.) Follow up

What are the three factors affecting adherence?

1.) personal factors 2.) Interaction with system 3.) treatment factors

Concordance

Agreement between doctor and patient on the use and reasons for use of medication

What is the #1 Reason for Neglecting to Fill Initial Prescription?

Condition improved

What is the primary reason prescriptions are left unfilled?

Did not need the medicine

Persistence

How long a patient remains on therapy

What is the mission of PQA?

Improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist-levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, health insurance plans, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payments models.

Medication Possession Ratio (MPR)

MPR= (Sum of days' supply for all fills in period/Number of days in period)*100

Proportion of Days Covered (PDC)

PDC= (Number of days in period "covered"/Number of days in period)*100

What is Compliance?

Patient follows the directions of the prescriber

What is the goal of Compliance and Adherence?

Patients take their medications as their physician indicated.

What is PQA?

Pharmacy Quality Alliance

How can health literacy be measured?

Rapid Estimate of Adult Literacy in Medicine Revised (REALM-R)

What is Adherence?

The extent to which patients take medications as prescribed by their health care providers under limited supervision in the face of conflicting demands

What does a modified Morisky knowledge score of 2-3 mean?

high knowledge

What does a modified Morisky motivation score of 2-3 mean?

high motivation

What does a modified Morisky knowledge score of 0-1 mean?

low knowledge

What does a modified Morisky motivation score of 0-1 mean?

low motiviation

Why do Oral Cancer Therapies require adherence?

■ Adults: Adherence and persistence 16-100% ■ Harsh side effect profiles

Why do Auto-Immune Disease medications require adherence?

■ Almost 50% are non-adherent ■ 50% risk of depression

How to overcome Distrust in health care or lack of relationship barrier

■ Develop a relationship with your patients ■ Take the time to listen and understand their concerns

Why do Bacterial and Viral Infections medications require adherence?

■ Drug resistance issues ■ Patients must finish ENTIRE prescription ■ Must treat appropriately

How to overcome Lack of understanding benefits barrier

■ EDUCATION: Teach patient about expectations, reasons for use, and side effects

how to overcome Physical Condition Barriers

■ Ex: Gout, Arthritis, Dexterity issues, Visual Impairment, Hearing Impairment ■ Use easy open caps ■ Special packaging ■ Print in large font ■ Speak with patients in quiet areas

how to overcome Financial Concerns Barriers

■ Help patient understand their insurance benefits ● Do they qualify for financial assistance programs? ● Are there insurances that are better suited towards their income? ● Work with patients about paying their co-pays ■ Work with providers to get patients generic therapies ■ Take advantage of low cost programs at certain stores

how to overcome Lack of follow-up Barriers

■ If possible, follow-up with your patients ■ If they are having side effects or concerns, schedule a follow-up call or appointment

how to overcome Psychiatric/neurological Conditions Barriers

■ Neurological- Will most likely forget to take meds ■ Psychiatric- May have difficulty remembering or feeling motivated to take meds ■ Set alarms on cell phone ● Apps like ScriptYourFuture will text reminders ■ Special Packaging ● Allows patients to put all of their meds together ■ Place meds in an area associated with daily activities ● Patient may remember to take meds in morning if near their cereal bowl, etc

Why do HIV medication require adherence?

■ Requires >90% adherence ■ Drug resistance affects 22% of patients

Why do Asthma/COPD medications require adherence?

■ Rescue vs. Chronic Inhalers ■ Patients do not realize implications of not taking therapies

How to overcome Polypharmacy and Complex Regimens barrier

■ Simplify medication regimens ■ Fill all meds at one pharmacy ■ Provide patients with special packaging

How to overcome Method of administration barrier

■ Talk with patients about concerns and fears ■ Teach proper technique ■ Demonstrate or provide handouts with patient specific language, in preferred language, with pictures ■ Promote Self-Efficacy

how to overcome language and Literacy Barriers

■ Use PATIENT-SPECIFIC language ■ Keep it at a 3rd grade reading level ■ Provide patients with information in their preferred language

Methods to Assess Medication Adherence

○ Calculations ○ Ask Patient Questions like

What are the top Diseases that REQUIRE Adherence?

○ HIV ○ Auto-Immune Disease ○ Asthma/COPD ○ Bacterial and Viral Infections ○ Oral Cancer Therapies

What is Intentional Non-Adherence?

○ Patient is choosing to not use treatment or follow recommendations ○ The patient weighs the pros and cons of treatment

Describe the Burden of Non-Adherence (Cycle)

○ Poor Medication Adherence→ Poor Health Outcomes→ Increased Service Utilization→ Increased Health Care Costs→ Costs Passed to the Patient

What is Unintentional Non-Adherence?

○ Unplanned non adherence ○ Due to forgetfulness, lack of understanding