An Introduction to Medication Adherence - (MAP) Medication Adherence Project A project of the Cardiovascular Prevention & Control Program and the ...

An Introduction to
    Medication Adherence
                       Medication
                    Adherence Project
                         (MAP)
A project of the Cardiovascular Prevention & Control Program and the Fund for
                          Public Health in New York

“Drugs don’t work in patients
   who don’t take them.”
              – C. Everett Koop

Epidemiology of Nonadherence
     • 50% of the US population is prescribed
       medication for chronic conditions

     • Of those prescribed medication, only 50%
       are taking it as directed

Sources: Angell SY et al. City Health Information. 2009;28:1-8;
Haynes RB. Compliance in Health Care. Johns Hopkins University Press;1979.

MAP Approach to
        Improving Adherence

• Promotes patient-provider communication
• Encourages self-management support
• Based on evidence
• Grounded in quality improvement principles

Adherence Improves Outcomes

Proportion with subsequent cardiovascular (CV) event (myocardial infarction, stroke, or coronary
  heart disease death) by the percentage of time in the past month when participants reported
                        Adherence and CVD Events
   taking medications as prescribed (P = .20 for proportion with events across all 4 adherence
 categories; P = .03 for proportion with events in patients with adherence 75% of the
                                               time)

CVD = cardiovascular disease.
Source: Gehi AK et al. Arch Intern Med. 2007;167:1798-1803.

    Copyright restrictions may apply.

Survival after Heart Attack
                                                                   Adherent

                                                            Nonadherent

Source: Ho PM et al. Arch Intern Med. 2006;166:1842-1847.

 Copyright restrictions may apply.

Adherence and HbA1c

 HbA1c = hemoglobin A1c.

Source: Rhee MK et al. Diabetes Educ. 2005;31;240-250.

Mean, Median, and Interquartile Range of the Proportion of Days Covered (PDC) by Statin for
       Adherence Diminishes Over Time*    Each Interval

 *Data shown is for adherence to statins

Source: Benner JS et al. JAMA. 2002;288:455-461.
    Copyright restrictions may apply.

Adherence to CV MedicationsRates of medication use for the entire cohort

Source: Ho PM .et al. Arch Intern Med. 2006;166:1842-1847.

Copyright restrictions may apply.

Starting Early

   •          Patients receiving brief in-office
              medication counseling after a new statin
              prescription were 17% more likely to
              continue filling prescriptions at 6 months

Casebeer L et al. BMC Fam Pract. 2009 Jun 30;10:48.

Non-adherence Costs
     •         Nonadherence is linked to higher
               medical costs for patients with diabetes,
               high cholesterol, or hypertension

Source: Sokol MC et al Med Care. 2005;43(6);521-530.

Total Costs and Adherence*

 *total healthcare costs for one year for patients with diabetes

Source: Sokol MC et al Med Care. 2005;43(6);521-530.

Barriers to Adherence

Patient Barriers
Complexity: “There are so many pills, I can’t keep them straight!”
Cost: “I can’t afford my medicine so I will only take half a pill today.”
Difficulty remembering: “I forget to take them.”
Lack of understanding: “Why do I need them?”
Not feeling sick: “I feel fine. I don’t need them.”
Side effects: “The yellow pills make me feel sick.”
Embarrassment/Stigma: “I don’t want my friends to know.”
Depression: “I don’t care…What’s the point?”
Health literacy: “I can’t understand these instructions!”
Belief systems: “My sister took insulin then had her leg amputated.”

Provider Barriers
Lack of time:
“The 15 minutes I have does not allow enough time to talk to my patients.”
Lack of resources and training:
“I’m afraid to ask – don’t want to open up Pandora’s Box!”
Lack of understanding:
“Why don’t my patients just do what I tell them to do?”
Lack of reimbursement:
”I don’t get paid to tell them how to take their medications and therefore
cannot afford to make time.”
Unaware of how to simplify regimens:
“How can I simplify – especially when my prescribing options are limited?”
Unaware of options for lower-cost medicines:
“I don’t know what to tell patients if they don’t have the money – I can’t tell
them to take half a pill.”

Pharmacist Barriers
Difficulty communicating with the prescriber:
“It’s hard to reach the prescribers to recommend changes in medication
in a timely manner.”

Language barriers:
“As a small business owner, I cannot afford to staff my pharmacy with
translators for all of the different languages my clients speak.”

Lack of time to remind patients to pick up medications:
“There are systems in place to flag patients who don’t pick up, but not
enough time to call them all.”

Provider Solutions

• “Normalize” nonadherence
• Ask about adherence at every visit
• Reconcile medications
• Simplify dosing and administration
• Prescribe long-lasting supply (90 vs 30
  days)
• Ask about costs, prescribe generics and
  refer to prescription assistance programs

Simplify Schedules

                                       85
                                                                       Adherence decreases with
               Rate of Adherence (%)

                                       80                              increasing dosage frequency
                                       75
                                       70
                                       65
                                       60
                                       55
                                       50
                                       45
                                            Once a day     Twice a day          Three times/day Four times/day

                                                          Medication Schedule

Sources: Osterburg L, Blaschke T. NEJM. 2005;353:487-497; Claxton AJ et al. Clin Ther. 2001;23:1296-310.

Prescribe Longer-Lasting Supply

     • Patients receiving 60-day supply (vs
       30-day) of statins were 1.4 times more
       likely to be adherent
     • Increasing prescription drug supply by
       30 days was associated with a 5.7%
       increase in mean adherence

Sources: Batal et al. BMC Health Services Research 2007; 7: 175, Schectman et al. Medical Care 2002; 40: 1294-1300.

Pharmacist Solutions
• Use systems that flag patients who missed refills
• Use stickers on bottles to identify patients who
  are late picking up refills. Speak to them about
  adherence
• Synchronize refill timings
• Suggest to patients to use one pharmacy for all
  of their medications
• Communicate with patients’ health care
  providers directly

Conclusions
• Medication adherence improves health
  outcomes and results in lower healthcare
  costs
• Nonadherence is widespread
• There are numerous barriers to adherence
• Regularly assessing patient adherence,
  improving communication, and addressing
  identified barriers can improve adherence

This slide set complements the Medication
 Adherence Project (MAP) Training Manual and
Toolkit. For these and other resources related to
medication adherence, go to www.nyc.gov/heart