Term
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Definition
• 30–50% of American adults are non-adherent
• Poor adherence has been associated with poor outcomes:
• ↑ complications and hospitalizations • ↑ risk of mortality
• >$100 billion in excess costs attributed to non-adherence annually |
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Term
| Medication Adherence: Barriers |
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Definition
• Unsure how medication will help • Benefits do not outweigh risks
• Too complex
• Denial or ambivalence
• Negative beliefs about medications • Lack of efficacy
• Cost
• Poor provider-patient relationship |
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Term
| Medication Adherence quote |
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Definition
“Increasing the effectiveness of adherence interventions
may have a far greater impact on the health of the population
than any improvement in specific medical treatments.” |
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Term
| Factors Associated With Medication Adherence |
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Definition
• Gender
• Race
• Drug regimen complexity/ease of use
• Polypharmacy
• Trust in providers
• Beliefs, religion
• Socioeconomic status
• Medication cost
• Disease, symptoms
• Medication adverse effects |
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Term
| Factors With Variable Impact on Adherence |
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Definition
• Health literacy
• Use of complementary and alternative medicine
• Social support
• Medication diaries |
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Term
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Definition
• No combination of factors can reliably predict adherence
• Non-adherence very common
All patients should be screened for non-adherence |
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Term
| How can you assess adherence? What questions would you ask? |
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Definition
Assessing adherence:
Be nonjudgmental! Patients need to be supported, not blamed.
Be empathetic.
Use open-ended questions.
Ask how often, not if.
Avoid asking “why” (negative connotation).
Do NOT interrupt patient (can actually make adherence worse).
Questions to ask:
Have you experienced any problems…?
Have you ever had difficulty…?
How often do you forget…?
Many people find it challenging….
Currently, no single scale evaluates all of the causes of nonadherence. |
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Term
| Strategies to Improve Medication Adherence |
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Definition
• Patient-provider interactions
• Drug selection and prescribing
• Reminders |
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Term
| Strategy: Patient-Provider Interactions |
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Definition
• Cognitive-based behavior change techniques (e.g., motivational interviewing)
• Shared decision making
• Self-monitoring for symptom improvement
• Provider consistency
• Strategic timing of follow-up visits
• Telephone follow-up
• More convenient care |
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Term
| Strategy: Drug Selection and Prescribing |
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Definition
• ↓ number of medications
• Prescribe low-cost, generic medications when available
• ↓frequency(e.g.,useextended-release formulation)
• ↓complexity(e.g.,insulinpenoverinsulinvial)
• Consider palatability, patient-preferred formulations
• Provide written information |
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Term
| Strategy: Reminders and Reinforcement |
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Definition
• Enroll in automatic refills
• Synchronize refills
• Associate with daily routine
• Pill organizer
• Email, phone, or text message reminders • Visual aids
• Financial compensation |
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Term
| Strategy: Future Directions |
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Definition
• mHealth
• Text messages
• Smartphone applications
• “Smart” devices |
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Term
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Definition
• CMS Medicare Star Quality Program
• Five-star rating system for health plans
• Information for consumers
• Performance-based reimbursement
• National recognition
• To earn five stars, >75% of covered beneficiaries must obtain ≥80% of prescribed medications from three initial drug classes
• Hypoglycemic drugs
• Statins
• Antihypertensives (ACEI, ARB) |
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Term
TL is a 72-year-old man who states, “I keep getting mixed up about which medications I am supposed to take in the morning and which ones I have to take at night. Sometimes I just forget to take them altogether.”
What tools and strategies would you use to improve TL’s adherence? |
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Definition
So forgetfulness is one of the barriers. And perhaps the complexity of his medication regimen is a barrier as well. So there may be an opportunity to change the timing of his medication.
Maybe we could prescribe fewer medications. We could associate taking that medication with a daily task, like brushing his teeth or having dinner.
And setting some kind of reminder, like if he has a smartphone, setting an alert, or some other means to remind him to take his medications might be helpful for TL. |
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Term
EM is a 45-year-old woman with diabetes mellitus, hypertension, and dyslipidemia. At her last visit 3 months ago you prescribed Lipitor (atorvastatin). EM started taking Lipitor, but her friend told her that it can cause muscle problems so she stopped taking it.
What tools and strategies would you use to improve EM’s adherence? |
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Definition
Are reminders and pillboxes going to be helpful in this case? Probably not.
The issue here is not about forgetfulness. She chose to stop taking it, because she was worried about a side effect that her friend told her about.
So for her situation, we want to focus on making sure that she understands the medication, why she is on the medication, the benefits of taking the medication, ways that we can monitor and reduce the risk of her having muscle problems, putting that risk in context.
So we talk about adverse effects. It's really helpful to express that rather than saying that it's rare. We're saying that it's a percentage of patients.
The most effective way to communicate the risk to patients, and actually to clinicians as well, is to say 1 in however many patients. So if it's less than 1%, we should say that it's less than 1 in 100 patients will experience that problem. That will really help her understand the relative risk versus the relative benefit of being on that medication.
So in conclusion, it's important that we evaluate all patients for adherence, that we try to understand and identify the barriers, and that we develop a patient-specific plan to address those barriers, and that we document that plan, and that you treat it with the same seriousness and prioritization that we would any other major medical condition, because it's only the medications that the patient takes that really have a benefit. |
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