Medication non-adherence and asthma treatment cost Bruce G. Bender a and Cynthia Rand b

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1 Medication non-adherence and asthma treatment cost Bruce G. Bender a and Cynthia Rand b Purpose of review The purpose of this review is to describe the impact of asthma treatment non-adherence on patients and the healthcare system, and to outline areas of responsibility towards improved adherence. Recent findings The average cost of healthcare expenses for each person in the United States in 2002 was US$5440. In that year, there were 800 million medical encounters. However, adherence research suggests that a significant portion of the healthcare advice and prescriptions dispensed in these encounters was wasted. The annual cost to the healthcare system caused by non-adherence has been estimated at US$300 billion dollars. The responsibility for improving adherence has usually been placed on the patient and healthcare provider. However, if non-adherence is to be more effectively addressed, other components of the healthcare and pharmaceutical industries must also take responsibility. Summary Treatment non-adherence compromises treatment effectiveness and drives up the healthcare costs related to asthma and other chronic conditions. Collaborative efforts to improve adherence to treatments for chronic illness, recently promoted by the World Health Organization, must include multiple components of the healthcare system, must recognize that the costs of adherence promotion are outweighed by cost savings after improved adherence, and must support research to develop new and better strategies for improving adherence. Keywords adherence, asthma, cost Curr Opin Allergy Clin Immunol 4: # 2004 Lippincott Williams & Wilkins. a Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado, USA; and b Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland, USA Correspondence to Bruce G. Bender, PhD, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO 80206, USA Fax: ; benderb@njc.org Current Opinion in Allergy and Clinical Immunology 2004, 4: Abbreviation WHO World Health Organization # 2004 Lippincott Williams & Wilkins Introduction Patient non-adherence to treatments for chronic illness compromises treatment success and patient quality of life while increasing healthcare costs. A recent World Health Organization (WHO) book addressed the worldwide problem of treatment non-adherence, which averages only 50% in developed countries and is even lower in developing countries, and concluded that increasing adherence may have a more beneficial impact on the health of the population than improving specific treatments [1.. ]. The WHO report is targeted at policy-makers and health managers in order to increase awareness of the far-reaching problem of poor adherence rates among patients with chronic illness and to stimulate multidisciplinary efforts to increase adherence. Healthcare costs related to non-adherence The United States is the largest consumer of healthcare in the world, with total health costs reaching US$1.6 trillion in 2002, representing 14.9% of the gross domestic product [2]. The average cost of healthcare expenses for each person in the USA in 2002 was US$5440, with an average of 3.1 physician office visits per person [2], resulting in a total of over 880 million physician office visits. However, adherence research suggests that a significant portion of the healthcare advice and prescriptions dispensed at these 880 million medical encounters was wasted. DeMatteo [3] estimated that over 188 million medical visits result in patients failing to adhere to physician advice. Although acknowledging that it is impossible to estimate precisely the waste and excess cost associated with non-adherence, the meta-analysis by DeMatteo [3] on the prevalence of non-adherence suggests that the costs may be as high as US$300 billion a year. Even more troubling are the healthcare costs resulting from non-adherence-related disease exacerbations. For example, when a non-adherent asthma patient presents with continuing symptoms, the physician may unnecessarily step up therapy because he or she believes that the patient is non-responsive to the original less intensive, and less costly, therapy. In addition, when a patient fails to respond to an apparently appropriate therapy, the physician may feel compelled to order expensive diagnostic tests to try and understand the patient s poor response to treatment. Although not all non-adherence results in dangerous or costly complications, research across a range of chronic diseases, including asthma, suggests that non-adherence results DOI: /01.all cf 191

2 192 Outcome measures in excess urgent care and hospitalizations. For example, Milgrom et al. [4] demonstrated that pediatric asthma patients who were the least adherent were more likely to have asthma exacerbations requiring a prednisone burst. On a national level, Iskedjian et al. [5] estimated the economic burden of hospitalization attributable to patient non-adherence with controller therapy in Canada. Using national health statistics and an average admission rate as a result of non-adherence of 5.2% (based on literature review), they concluded that Canadian hospital expenditures caused by nonadherence exceeded US$1.6 billion. Finally, even when patients follow physician advice as far as filling prescriptions and initiating therapy, research suggests that a portion of all prescribed medication is wasted or discarded. For example, a study by Morgan [6] used home-based pill counts and surveys to examine the economic impact of wasted prescriptions among older outpatients (465 years). Morgan [6] found that waste (i.e. no intention of using remaining medication) represented 2.3% of total medication costs and that the average annual cost of the wasted medication was US$30.47 (range US$ ). The study estimated that this modest perperson cost of waste would translate into a national cost for adults older than 65 years of age of over US$1 billion per year. The overall implications of these analyses are clear and compelling. As healthcare costs spiral upwards and national health policy debates consider severe limitations on healthcare benefits, strategies to reduce non-adherence-related costs offer a promising (and cost-effective) avenue for intervention and cost-savings. Changing patient behavior Despite a large published literature addressing the problem of how to change patient behavior in order to improve medication adherence, remarkably little success has been recorded. Patients in adherence intervention studies may achieve higher scores on a test of asthma knowledge, and report increased medication use, but most frequently an objectively established change in disease status is not achieved [1..,7]. Because many factors can contribute to treatment non-adherence, no single intervention will affect change in each individual. Patient understanding of the disease and its treatment is essential for treatment adherence and improved outcomes, but studies employing comprehensive asthma education programmes often do not result in significant change [1..,7]. Patient education remains an important component in the comprehensive care of asthma, but it is likely to affect change only in that group of patients for whom a lack of information is the primary reason for non-adherence. Changing adherence behavior is a difficult but not impossible task. Smoking, which is both physiologically and psychologically addicting, is a behavior very resistant to change. Nonetheless, comprehensive efforts to reduce smoking frequency have resulted in a decrease over the past 25 years in the proportion of Americans who smoke. Furthermore, the Surgeon General s Report in 2000 outlined a plan for cutting US smoking rates in half that included: (1) the implementation of school-based antitobacco programmes; (2) a media campaign including anti-tobacco messages from popular celebrities; (3) encouragement of the inclusion of state-of-the-art smoking cessation programmes in health insurance plans; (4) the training of physicians to address tobacco cessation more effectively; (5) the passage of legislation that would include stricter indoor air regulations; and (6) increased funding to develop more effective smoking cessation interventions. The application of a broad spectrum of strategies that influence behavior may similarly help to improve the self-management of chronic medical conditions including asthma, diabetes, and hypertension. Whereas the healthcare provider has the most direct contact with patients and therefore the greatest opportunity to affect behavior change, the caregiver cannot alone improve the patient s management of chronic illness, relieve the patient of disease burden, and reduce healthcare costs. In a recent report, WHO sited the worldwide problem of the treatment of non-adherence in both developed and developing countries and across all chronic conditions, including communicable diseases such as tuberculosis and HIV/AIDS, mental and neurological conditions such as depression and epilepsy, substance dependence, and a range of other conditions including asthma, hypertension, and cancer. The international panel of writers of the WHO report took the following position with regard to which elements of the healthcare system must assume responsibility for improving disease management: Over the past few decades we have witnessed several phases in the development of approaches aimed at ensuring that patients continue therapy for chronic conditions for long periods of time. Initially the patient was thought to be the source of the problem of compliance. Later, the role of the providers was also addressed. Now we acknowledge that a systems approach is required. The idea of compliance is associated too closely with blame, be it of providers or patients, and the concept of adherence is a better way of capturing the dynamic and complex changes required of many players over long periods to maintain optimal health in people with chronic diseases [1.. ]. Widespread change in the patient self-management of chronic illness will occur when, as with the campaign to

3 Medication non-adherence and asthma treatment cost Bender and Rand 193 lower smoking rates, the problem is approached from multiple avenues using multiple strategies. To accomplish this, neither the patient nor the healthcare provider can be expected to assume sole responsibility for effective disease self-management. The healthcare provider, healthcare industry, and pharmaceutical industry must all accept responsibility for helping enable patients to care for their asthma better. Healthcare provider The relationship between the healthcare giver and the patient has a large influence on whether the patient will engage in healthcare behaviors sufficient to ensure successful treatment of the disease. The Expert Panel Report: Guidelines for the diagnosis and management of asthma [8] emphasized that patient education must occur within this caregiver patient partnership. This relationship has a more powerful influence on adherence than almost any other factor [9,10]. The strength of the physician patient treatment alliance, as rated by the physician, predicted treatment adherence and non-routine office visits in the year after hospitalization of 60 adolescents with severe, chronic asthma [11]. In psychotherapy for emotional disorders, stronger therapeutic alliance has similarly been positively related with better outcomes [12]. In some cases, the behavior and attitude of the patient prevents the healthcare giver from developing an optimal working relationship. However, there is considerable evidence that the behavior of the physician plays a significant role in defining the strength of the treatment alliance. Patients are more adherent to their treatment regimen when their physician has answered all the patient s questions [13] and communicated clearly [14] and positively [15. ]. The physician s interest in spending time with a patient, attempting to understand his/her beliefs and perceptions about the illness, communicates the desire to develope a partnership that will result in treatment success [15. ]. Healthcare industry The healthcare industry includes insurance companies, health maintenance organizations, and the hospitals, clinics, and medical centers that provide clinical care. The needs and objectives of these organizations are sometimes in conflict. For example, the amount and type of healthcare that medical facilities may wish to offer is restricted by patients healthcare insurance policies. Furthermore, the need for insurance providers and health maintenance organizations to remain profitable may at times conflict with the patient s wish to receive quality healthcare in a rapid and unrestricted manner. Nonetheless, the objectives of increased patient adherence and consequent improved disease control are in the best interests of both the healthcare industry and the patient. Patients who are adherent to their treatment plan and are able to self-manage a chronic illness effectively are less burdensome to healthcare providers. Such patients are less frustrating to their provider and are less likely to require emergency medical services, in turn saving money for the insurer. Because many emergency room visits and hospitalizations for asthma can be traced to treatment nonadherence [16], increased adherence can be cost saving for insurance and health maintenance organizations. Inadequate disease management frequently underlies the largest healthcare costs related to asthma, including on average more than US$500 per emergency room visit and US$2000 per hospitalization [17]. Urgent care, including hospital stays and visits to the emergency room or urgent care clinic, amount to almost US$2 billion [18]. When indirect costs such as work absenteeism are taken into account, the total cost of poorly controlled asthma is much higher [19]. The potential cost-savings achieved by promoting adherence must be weighed against the apparent cost savings of restricting access to care, shortening office visits, and passing increasing medication costs to patients. Physicians and other care providers who experience pressure to see more patients in shorter office visits often report that they are allowed insufficient time to address patient adherence [20]. If increased emergency room and hospital visits by patients who are not well motivated or informed about caring for their illness are at least partly the result of shortened office visits, then the apparent cost savings resulting from seeing more patients in less time are not real. Similarly, the apparent cost savings anticipated when insurance companies shift increasing medication cost to patients must be calculated against the cost resulting when patients stop taking medication for their heart disease [21]. Pharmaceutical industry Drug development, manufacturing, marketing, and pricing all have a potential impact on patient acceptance and adherence. That patients are more adherent to medications that are easily taken has been understood for many years [22 25]. Recognizing these phenomena, pharmaceutical firms have increasingly attempted to develop once-daily treatments, to obtain US Food and Drug Administration approval to convert multiple-dosing regimens to once a day, and to produce asthma medications with tablets rather than inhaler delivery systems. Developing medications with higher patient acceptance helps adherence, but the pharmaceutical industry could do more to assist in the pursuit of improved selfmanagement. Much of the research in the adherence to

4 194 Outcome measures asthma metered-dose inhalers has advanced because of the availability of electronic devices that allow researchers to collect information about the patterns of medication use. The most recent generation of dry-powder inhaled medications include a variety of delivery systems that do not accept electronic adherence-tracking equipment. As new asthma medications are developed, the inclusion of technology that can be adapted to monitor adherence would represent an important contribution to increasing patient adherence. Improvement in medication labels and package inserts may also promote better adherence. Most labeling regulations are content based, and few package inserts are written to be easily read by patients or to be informative and adherence promoting. Most patients throw away the inserts without reading them. An exception to this is found in Australia, where performance-based and tested package inserts are consumer friendly, written clearly and in a manner that makes them useful and encouraging to patients [1.. ]. Finally, it would be helpful for pharmaceutical firms to consider the growing phenomenon of patient rejection of new, expensive drugs for which they are expected to shoulder a large portion of cost in their insurance plan. The management of high medication costs must be the responsibility of the pharmaceutical industry as well as the health insurance industry, the care provider, and the patient. Conclusion Treatment non-adherence compromises treatment effectiveness and drives up healthcare costs related to asthma and other chronic conditions. The responsibility for improving adherence has usually been placed on the patient and healthcare provider. However, if nonadherence is to be more effectively addressed, other components of the healthcare industry must also take responsibility. Healthcare systems, including many health maintenance organizations, often direct the length and duration of treatment, including the amount of time healthcare givers are able to spend with patients. They determine reimbursements and fee structures, the allocation of resources for physician training, procedures for the continuity of care, and the manner in which information about patient progress is recorded and tracked. A consideration of their impact on adherence when health delivery systems are designed can contribute significantly to the improved self-management of asthma and other chronic illnesses. Finally, collaborative efforts to improve adherence to treatments for chronic illness, recently promoted by WHO [1.. ] may follow the success of anti-tobacco efforts, including an adherence-promoting message conveyed in the popular media, communication training for physicians, and increased funding to test new adherence intervention strategies. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as:. of special interest.. of outstanding interest 1.. Sabate E, editor. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; An international group of authors make the case for the large degree to which the treatment non-adherence in both developing and developed countries leads to poorly controlled illness. 2 National Ambulatory Medical Care Survey Available at: [Accessed 15 January 2004] 3 DeMatteo D. Variations in patients adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004; (in press). 4 Milgrom H, Bender B, Ackerson L, et al. Noncompliance and treatment failure in children with asthma. J Allergy Clin Immunol 1996; 98: Iskedjian M, Addis A, Einarson TR. Estimating the economic burden of hospitalization due to patient nonadherence in Canada. Value Health 2002; 5: Morgan TM. The economic impact of wasted prescription medication in an outpatient population of older adults. J Family Pract 2001; 50: Bernard-Bonnin A-C, Stachenko S, Bonin D, et al. Self-management teaching programs and morbidity of pediatric asthma: a meta-analysis. J Allergy Clin Immunol 1995; 95: National Heart Lung and Blood Institute. Expert Panel Report 2. Guidelines for the diagnosis and management of asthma. Washington, DC: US Department of Health and Human Services; Cromer BA. Behavioral strategies to increase compliance in adolescents. In: Cramer JA, Spilker B, editors. Patient compliance in medical practice and clinical trials. New York: Raven Press; pp Stewart MA. Effective physician patient communication and health outcomes: a review. Can Med Assoc J 1995; 152: Gavin LA, Wamboldt MZ, Sorokin N, et al. Treatment alliance and its association with family functioning, adherence, and medical outcome in adolescents with severe, chronic asthma. J Pediatr Psychol 1999; 24: Krupnick JL, Sotsky SM, Simmens S, et al. The role of the therapeutic alliance in psychotherapy and pharmocotherapy outcome: findings in the National Institute of Mental Health treatment of depression collaborative research program. J Consult Clin Psychol 1996; 64: DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians characteristics influence patients adherence to medical treatment: results from the medical outcomes study. Health Psychol 1993; 12: Armstrong D, Glanville T, Bailey E, O Keefe G. 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